Study design and setting
This was a cross-sectional qualitative study that was conducted as part of a larger mixed methods study aimed at estimating the incidence of abortion, severity of abortion-related complications, cost, and quality of post-abortion care in Liberia and Sierra Leone. The qualitative study focused on describing the perspectives of healthcare providers and policy actors on the access and provision of quality PAC in the two countries.
Liberia and Sierra Leone are both West African countries that border each other and have an estimated population of about 5 million and 6 million respectively. Abortion laws in both countries are largely restrictive, where in Sierra Leone, abortion is allowed only after a licensed physician determines that continuing the pregnancy poses substantial risks to the fetus or woman's physical or mental health and if the pregnancy resulted from rape or incest. The restrictions mentioned are similar to Liberia. Currently, there are ongoing legislative and policy processes in both countries; for instance, in Liberia, a proposed public health law strives to make abortion legal up to 18 weeks of pregnancy if it is done by a doctor while in Sierra Leone, there is an ongoing development of the Safe Motherhood & Reproductive Health Bill, aimed at facilitating increased access to information and services related to sexual and reproductive health (SRH). This initiative seeks to empower women by enabling them to make well-informed decisions about their reproductive health, thereby mitigating the risk of unsafe abortions.
Study Population
The study population encompassed health providers, such as nurses, midwives, doctors, and specialists (e.g., gynecologists) involved in the provision of PAC services in selected health facilities in both countries. In addition, policy actors represented individuals from the ministries of health in Liberia and Sierra Leone, and from civil society organizations and non-governmental organizations working in sexual and reproductive health and rights issues in both countries.
In Sierra Leone, we interviewed 5 health providers from primary facilities and 20 from secondary facilities. Out of the 25 health providers, 4 were Doctors/gynecologists while 21 were nurses/midwives. We also interviewed 5 policy actors, who were all health managers. In Liberia, our study population comprised of 3 health providers from tertiary facilities, and 5 secondary facility levels. Of the 8 health providers, 2 were doctors, and 6 midwives/nurses. Additionally, we interviewed 8 policy actors, (including 4 program officers and 4 health managers)
Sampling and recruitment
We purposively selected healthcare providers from the targeted hospitals, health centers, and clinics in Liberia. While in Sierra Leone, we selected National referral hospitals, regional hospitals, and district hospitals. At large referral hospitals, participants were the head of the obstetrics and gynecology departments or a key obstetrician-gynecologist working in the facility. However, at lower-level facilities, a nurse, a midwife, or another health worker who was knowledgeable about PAC services provided in the facility was interviewed.
The policy actors from both countries were purposively sampled based on their level of knowledge and expertise in SRHR issues. These policy actors included representatives from religious institutions, ministry of health, civil society organizations, non-government organizations such as program implementers and officers.
Data collection Process
In both countries, we conducted in-depth interviews with healthcare providers from a sample of primary, secondary, and referral facilities across Liberia and Sierra Leone. To triangulate data from the healthcare providers, we also conducted key informant interviews with policy actors. We recruited two research assistants in Liberia and 10 in Sierra Leone with previous experience conducting qualitative data collection. The research assistants were taken through a five-day training that covered study objectives, aims of the qualitative study, target population, ethical considerations, and interviewing and observation techniques as well as how to address any psychological risks to study participants, should they occur. They also participated in pre-testing and reviewing of interview guides to assess the feasibility of the study in local settings, test and evaluate the design of the instruments, and affirm the validity and reliability of the tools. All participants consented to the study before interviews were conducted in quiet and private spaces. All the interviews were audio-recorded (with additional permission by the participants) and notes taken.
During the entire study period, critical attention was paid to COVID-19 risks. Digital options including virtual meetings were used in cases where physical meetings impossible. Our study staff were also provided with information and resources, including brochures and posters, verbal communication, to help them understand what COVID-19 was and how it spreads, and preventative practices. Additional personal protective equipment such as gloves, masks, and hand sanitizers were provided. Data collection took place between October 2020 and February 2021.
Data Analysis
All interviews were transcribed verbatim to English and back translated by trained qualitative transcribers. Two of the co-authors who are anthropologists developed the codebook with inputs from co-authors and performed data coding and analysis. The codebook was reviewed extensively by the study team while referring to the transcripts used, interview guides, and study objectives. Two transcripts from the provider and policy actor interviews, respectively, were selected for inter-coder reliability test to assess the consistency in coding between the two coders. A thematic approach was used to analyze the data.
Ethical Consideration
Findings
Analysis of the interviews revealed four distinct themes and sub-themes, reflecting on the perspectives of health providers and policy actors on the quality post-abortion care provision and challenges in Liberia and Sierra Leone. The four themes were—1) the capacity of health facilities to provide PAC, 2) unclear policies, guidelines, and laws around PAC, 3) religion as a barrier to PAC, and 4) patient perception of PAC as a last resort.
Before delving into the four themes, we first provide participants’ understanding of quality post-abortion care. Participants from both countries recognized the critical role of quality post-abortion care in averting severe maternal outcomes, such as maternal near-miss and deaths resulting from abortion complications. However, there were differences in how some health providers and policy actors defined quality post-abortion care. Some argued that quality post-abortion care is a comprehensive package of essential elements that include availability of skilled and trained providers of PAC, equipment and supplies for PAC, and timely delivery of service. One policy actor in Sierra Leone was emphatic that PAC is only considered as quality when the various elements are all present and that, in case any is absent, care ceases to meet the quality criteria. For instance, they argued, “if you have trained and qualified staff but lack equipment and drugs, there are no quality PAC services…”
On the contrary, a health provider in Liberia considered PAC as quality based on the process elements of care and focusing on the technical suitability of care procedures, such as capturing patient history, examination, treatment of complications, counselling, and referral where needed, as indicated in the quote below:
You take the patient's history, conduct examination, treat with antibiotic in case of infection and, if in-complete abortion, you evacuate the retained products, then discuss follow-up visit, then deliver family planning counselling (Midwife, Secondary Facility, Liberia).
The range of perspectives highlighted above reflect the variations in views that health providers have on quality PAC and that influence their routine clinical practice and response to patient’s needs and justifies the need for greater dissemination of PAC standards and guidelines in both countries.
The below sections present key themes that highlight the aspects of PAC and the challenges and experiences around delivery of PAC in Liberia and Sierra Leone.
Capacity to provide post-abortion care
The capacity of health facilities to deliver PAC was characterized in our analysis with the availability of PAC equipment and supplies, PAC referral system, PAC Infrastructure (e.g., shared consultation rooms), and PAC training and skills.
a) PAC equipment and supplies
PAC-specific equipment and supplies (such as manual vacuum aspiration set and antibiotics) are indispensable in the delivery of quality and comprehensive PAC. Interviews with health providers and policy actors in Liberia and Sierra Leone revealed rampant absence of essential equipment, especially in primary-level facilities, but also in some secondary facilities. A policy actor in Liberia reflected on this challenge and indicated that it was commonplace in facilities across the country:
The resources are inadequate in terms of the MVA kits [equipment]; most facilities do not have MVA kits, and this makes PAC service provision difficult… (Senior Official, MOH, Liberia)
Consequently, patients presenting at such facilities may not get PAC and, as described by a provider in Sierra Leone, they tended to examine and refer all their PAC patients to higher-level facilities for appropriate care:
We refer to bigger facilities because we do not know the severity of the thing that they have done already to remove the pregnancy, and we do not even have the MVA equipment (Midwife, Primary Facility, Sierra Leone).
Referral of PAC patients to higher level facilities presents logistical and cost challenges to patients and sometimes leads to extensive delays in care, further worsening the situation. Participants told us that the lack of equipment in public health facilities in Liberia forced some women to seek care in private health facilities, where the charges are higher and some women or households may be unable to afford, thus limiting access to timely care or sometimes incurring catastrophic health expenditures:
They do not have the equipment…the woman might have to go to a private facility who then would charge, what they want (Program Implementer, INGO, Liberia).
However, few providers in secondary facilities indicated they had the necessary PAC equipment, even though they were in poor working conditions. For instance, a provider in Liberia lamented on how the available MVA kit was rusty and faulty or incomplete, and that she had ‘’been using the same equipment for a long time now…it is rusted and became hard to use.’ The same situation was noted in Sierra Leone, as alluded to in the quote below:
We do not have enough instruments to perform PAC services, and some are not in working conditions. So, we find it difficult… (Midwife, Secondary Facility, Sierra Leone).
The condition of PAC equipment was linked to lack of proper maintenance. One provider noted that “there is no proper monitoring (maintenance), so equipment gets easily spoiled.” Few providers in Sierra Leone also admitted to mishandling the available MVA kits, by failing to properly sterilize and store them as required after use. Using equipment that are not properly functional inflicts pain and infections, exposing the patients to new complications. A midwife from Liberia warned of the negative implications of using faulty equipment: “you cannot use dirty or faulty instruments for doing PAC because that can do more harm.”
Health providers voiced frustrations about having to use non-functional equipment; some resorted to purchasing their own MVA kits that are only used in the facility when the owners were present. While this strategy helped to sustain the provision of PAC services to patients, it was limiting and inconsistent, especially on days when providers who owned the equipment were away. A midwife from a facility in Sierra Leone explained that:
… MVA equipment are not there readily even when there is a uterine evacuation case. They are privately owned … If there is a case requiring MVA, we call the owner of the instrument who must come and do it (Midwife, Secondary Facility, Sierra Leone).
Health providers and policy actors emphasized that quality PAC remains difficult to achieve in health facilities if essential PAC supplies and commodities (e.g., blood, sterile gloves, gauze, pregnancy kits, medication abortion drugs, antibiotics, and pain medication) are unavailable. PAC supplies (e.g., gauze and sterile glove) are crucial for facilitating examination and effective treatment and prevention of complications, such as infections. Interviews with providers suggested that unavailability or stock-outs of PAC supplies was more pronounced in Sierra Leone compared to Liberia. Providers in Sierra Leone decried the rampant stock-outs and the effects this has on PAC patients, who often end up being sent to private pharmacies, incurring extra and higher costs, as noted in the quote below:
Sometimes not all the drugs are available…it can take two or three months without drugs…you may want drip [Intravenous drip] you need injection, you must prescribe medicine and tell them (relatives) to buy and bring to us... (Midwife, Primary Facility, Sierra Leone).
Some providers in Sierra Leone resorted to using their own money to get the necessary supplies and commodities to ‘save the woman’s life’, but this practice became overwhelming and unsustainable as patients increased. This view is captured succinctly as a provider said:
Sometimes we do not have these drugs [misoprostol] to save life, we use the misoprostol to control the bleeding [during evacuation of the conceptus]…you have to take your money to buy it because you do not want to lose the patient… (Midwife, Primary Facility, Sierra Leone).
Providers in Sierra Leone blamed the PAC situation in their health facilities on limited support from the government:
The government is not providing supplies for free health services, especially in the area of maternal care and we are struggling over that, it is stressful (Midwife, Secondary Facility, Sierra Leone).
While stock-outs of PAC supplies and commodities was not severely mentioned in Liberia, providers revealed that patients are often made to pay extra costs to cater for certain supplies needed for care at their facilities. In both countries, providers cited extensive delays in the provision of PAC whenever patients lacked money to pay.
b) PAC referral system
Referral of PAC patients to higher-level facilities was noted as a frequent practice when facilities lacked functional PAC equipment and essential supplies and in cases where patients had severe complications requiring advanced attention. However, providers enumerated challenges they encounter during referral, such as absence of properly equipped and staffed ambulances, and the use of public transport systems, as noted in the quote below:
If the ambulance is not available, then they have to find a commercial vehicle to carry them or sometimes we have to use our own money to save women’s lives (Midwife, Secondary Level, Liberia).
Health providers in both countries admitted to facilitating the referrals of PAC patients who were in critical conditions and acknowledged that this weighed them down whenever they could not help all the patients in need. Further, engaging and relying on the patients' relatives to cater for patients' referral caused delays and risk loss of lives.
c) PAC Infrastructure: shared consultation rooms
In both countries, providers decried the poor PAC infrastructure in health facilities and noted that PAC examination and consultation rooms often lacked both audio and visual privacy. Providers in Liberia, especially those in primary facilities described how they often treat PAC patients in shared rooms within the ANC department, labor, and delivery wards, and that they have no curtains or screens to shield patients. In one instance, a provider in Liberia said that ‘’they have stretchers, wheelchairs…and if the couch is available we will use it to do the examination and screening.” Such practices, while normalized, deprived patients of privacy, confidentiality, dignity, and stigmatized them, thus affecting the overall quality of PAC, and the patients are unable to be truthful about their reproductive and pregnancy histories, especially if they had induced abortions. Providers in Sierra Leone warned of the dangers of incomplete or inaccurate history that may lead to misdiagnosis of the patient’s condition. The below quote illustrates this situation in Sierra Leone aptly:
The facility is small for the number of patients we get…the number is large, there is no privacy.... When they arrive, they will not tell you exactly what they have done, they will just say that they are bleeding… (Midwife, Primary Facility, Sierra Leone).
PAC services in rooms or spaces devoid of privacy and confidentiality complicated patient-provider interactions. Such interactions were characterized by tensions, fear, threats, and frustrations, and providers cited situations when patients simply refused to speak: “Sometimes we even threaten that if you do not talk we will not help you…if you tell me what you have taken, that can guide us on how you will be treated.”
Abortion stigma curtails open conversations between patients and providers, especially during patient history. There was a consensus among providers in both countries that patients would communicate freely in spaces that have audio and visual privacy because some patients “are highly ashamed and would not like their relatives to know their secret”. A provider in Sierra Leone emphasizes the critical value of ensuring patients are in safe spaces during consultations:
The majority of girls that carry out criminal abortion will not say it. She will come and just say to the nurse, ‘I am feeling stomach pain’ and you will treat her for stomach pain… (Midwife, Primary Facility, Sierra Leone).
The provider also noted that, ‘’when you are both in a comfortable and private place, you can even get more information about the patient…’’ It is noteworthy that some providers navigated these challenges by talking in low tones and relocated the patient to different rooms or spaces. Within treatment rooms, some providers also used screens and covers though some were torn or worn out.
d) PAC training and skills
In Liberia, interviews with providers suggested that most providers had been trained on PAC and could perform surgical evacuation procedures (using MVA) or with medications (using misoprostol), including offering family planning counselling. Providers in Liberia associated their capability to deliver PAC services to the training, with one narrating that—we went for the EMOC training, and we were also enlightened on the management of PAC. Providers who are trained tended to have great confidence in delivering PAC services, interacting with patients with ease, obtaining patient history, and keeping the patient calm during MVA procedures as highlighted in the quote below:
I have been very efficient when it comes to providing PAC…for those women and it helps reduce some complications (Midwife, Secondary Facility, Liberia).
On the other hand, interviews with providers in Sierra Leone showed that providers lacked adequate training on PAC services, and this sometimes led to severe maternal outcomes, including death:
There was a time a lady came with an induced abortion case; the pregnancy was seven months, and she induced the termination and came in for ‘crushing’ [safe evacuation] but unfortunately, I [trained provider] was not present. Things did not go well so the patient died, and the doctor ran away… Had the doctor known what to do, I guess the patient should not have died (Midwife, Secondary Facility, Sierra Leone).
Second trimester abortion is generally risky and must be handled by well-trained personnel. In the case reported above, the woman self-induced at home, implying that the wrong methods were employed. Critical and high-quality emergency care (PAC) for such a patient is essential to save her life, but where such is unavailable, the outcomes can be fatal. Health providers and policy actors in both countries highlighted the role of PAC training in improving quality care and health outcomes, even though the exercise can be resource demanding:
If you have the resources and have trained staff… it would definitely reduce the number of deaths resulting from abortion… (Senior Official, INGO, Sierra Leone).
Training new providers logically is resource-straining and, as such, it is difficult to monitor the progress or quality of PAC service delivery at the facility level… (Midwife, Tertiary Facility, Liberia).
Training modalities also emerge as a key point from the data, with providers highlighting the dynamism and evolution of medicine and the need for continuous refresher training through in-service training of providers to update their knowledge on current best practices, clinical guidelines, new technology and medicines. Below are reflections from providers in both countries:
Since the time I did that training, I do not have any memory of the knowledge, we need refresher training so that our brains would not sleep [become obsolete]… (Midwife, Secondary Facility, Sierra Leone).
Training should be conducted regularly to remind and update us on new technology and guidelines….; training provided in school is not enough because if you study and you do not practice, you always forget (Nurse, Secondary Facility, Liberia).
Even though some facilities had trained staff in Liberia, participants told us that sometimes the patient volume overwhelmed the providers, leading to exhaustion and burnout. In addition, understaffing and staff transfer affected the provision of PAC, especially in facilities with only one trained PAC provider:
After teaching and training staff (PAC providers), staff rotation happens, and they move to other facilities, and you have to do training afresh. We are staffed but for at least three years we do not want them to make a change in rotation so we can see the result of mentorship and we can monitor quality care (Senior Official, MOH, Sierra Leone).
These disruptions in human resources sometimes made it hard to assess, monitor, and track investments and changes in quality of PAC in facilities even after training.
Unclear policies, guidelines, and laws around PAC
Our data showed that in both countries providers had limited understanding of the existence and contents of available laws, policies, and guidelines around abortion and PAC. Providers often hesitated to provide PAC for fear of being stigmatized or arrested. A senior official, MOH in Liberia shared that – the current law contributes greatly to whether women seek PAC because they are stigmatized. Many service providers and communities are not informed that these people have the right to services. Such lack of knowledge influenced providers' attitudes towards PAC patients and how they treated them.
A common misconception among some health providers and policy actors in both countries was that patients who sought PAC had induced abortion, and were hesitant to treat patients as a punishment or a lesson to them, as shown below:
Most of the clients who came in with an induced abortion case some colleagues most times refused to attend to them because they are the ones that tried aborting the pregnancy (Midwife, Secondary Facility, Sierra Leone).
Once someone (a woman) arrives with an incomplete abortion, sometimes they are not prioritized by the service providers or are not given the services because it is an abortion. And because of the stigma, adolescent women shy away from seeking PAC (Religious leader, Liberia).
Consequently, participants told us that patients delay to receive treatment or are turned away without care, increasing the risk of poor maternal outcomes. In other facilities, providers reportedly exploited the stringent abortion laws and imposed exorbitant service charges on PAC patients. PAC patients are sometimes desperate and present with life-threatening conditions, hence, they or their relatives often have no choice but to pay. A policy actor in Liberia shared some reflections as indicated in the quote below:
….PAC is free of charge, but in reality, that does not exist…people who are managing PAC cases think that the person involved has done something illegal, therefore they charge what they want, and it is quite expensive (Program Implementer, INGO, Liberia).
Even though PAC is supposedly free in both countries by government policy, and most patients have this expectation, when charged a fee, some cannot afford causing delays in care. Providers acknowledged that they do/did that to deter patients from attempting the same in future. In Sierra Leone, a provider admitted to coercing patients to pay for PAC, indicating that —we cannot offer that service when one reports an induced abortion, they must pay for that. Such practices only push women away from health facilities, as observed in both countries. A participant in Liberia warned of the dangers of such practices:
When you turn somebody away and say I cannot help you, (.) the next time you see her, she might be on the stretcher, bleeding– HB is now four and you are the one that will be running around, if you are lucky you might get her back if you are not she dies (Program Implementer, INGO, Liberia).
Some providers conceded that they do not document PAC cases at the facilities due to fear. Lack of or inadequate documentation of PAC cases in Sierra Leone was cited as an impediment to quality PAC. As explained by a policy actor in Sierra Leone, lack of documentation limits knowledge on the PAC caseloads at the facilities, management procedures, and outcomes of care. Whereas some providers were deliberate about not documenting PAC cases, others admitted they were unaware it was necessary, as disclosed by a provider in Sierra Leone, “I came to learn it is important to document PAC cases when I was asked about the total number of abortion cases we had for the month”.
Religion as a barrier to PAC
Interviews with providers revealed the role of religion and morality in the provision of PAC. It was commonly noted that providers who identified as religious perceived that children are highly valued and considered gifts from God and abortion is a reprehensible act. As such, some providers felt justified in denying services or refuse to attend to PAC patients. As affirmed by a midwife in Sierra Leone, it did not matter whether the patient had induced or spontaneous abortion:
Some service providers do not provide PAC services because of their (religious and personal) beliefs. Even when patients came in on spontaneous abortion cases some of my colleagues refused to attend to them (Midwife, Secondary Facility, Sierra Leone).
As noted above for Sierra Leone, in Liberia, some providers considered the provision of PAC as an affront to their religious beliefs. A similar observation was in Liberia, where a policy actor noted that notwithstanding training, some religious providers still felt that they ‘were a part of taking life and they cannot be seen taking life.’ The views are succinctly summarized in this quote:
Some health workers have been trained to do PAC but have other values, religious values, and other principles that cannot allow them to assist [provide care] a woman in this situation… (Program Implementer, Liberia).
Following the religious barriers mentioned, policy actors in both countries felt value clarification, attitudes and transformation sessions should be included in the PAC training to clarify provider values and address abortion-related stigma.
Patient perception of PAC as a last resort
In Sierra Leone, some providers highlighted the sources of unsafe abortions and shared experiences of women who visit traditional doctors, commonly referred to as ‘pepper doctors’, ‘grannies’ and ‘mammies’. These traditional doctors, while trusted by the community, use unsafe methods and procedures to terminate unwanted pregnancies with resultant severe health implications:
The last time we did speculum examination, a cassava stick was in the cervix. We tried to remove it, but it was very long... They put it right inside the cervix. She went to someone and that is how the person did it to destroy the pregnancy. There was also a case in which a woman took a razor blade, ground it, and drank it. She ended up dying before this procedure [the termination] started (Clinical health officer, Secondary Facility, Sierra Leone).
Health providers recounted the way PAC patients often present at the facility, indicating that: “the unfortunate part of this is that, they will come to us after they have attempted to abort and complications set in.” Stigma and fear of exposure or arrest force patients to delay and only present at facilities when the complication becomes serious. A policy actor in Sierra Leone remarked that induced abortion patients preferred to hold on to the pain and bleeding for fear of exposure and stigmatization:
Women and girls do ‘under the table’ clandestine abortions and when complications arise, they will hold on at home in pain for the longest time because of not having a safe space to go (Senior official, MOH, Sierra Leone).
Similar reflections were echoed by policy actors in Liberia, saying that, PAC is available to all women, but a lot of women, because of the nature of abortion, would not want to seek services because they will be stigmatized. When patients come to the facility as a last resort, they are often in critical health conditions, with complications having worsened, and the survival of the patient depends on whether the facility has the proper resources (equipment, supplies, and trained health providers) to manage the cases.