This study reveals gaps in SBAs’ knowledge and capacity to deliver high-quality PAC services at both public and private HFs. On average, SBAs at SHs, regional and provincial hospitals demonstrated greater knowledge of tasks required for high quality PAC than staff at other facility types. All SBAs should know the essential actions in management of complications of incomplete abortions, that includes recognizing the complication, checking vital signs and stabilizing the woman, providing IV fluids, assessing vaginal bleeding, and uterine evacuation using both MVA and misoprostol.16
Fewer than half of SBAs across all public and private HFs mentioned using MVA and providing family planning counseling to women; almost more than half of them named starting IV fluids, checking vital signs, and assessing for bleeding. The gaps documented in providers’ knowledge are consistent with the results of the 2010 EmONC assessment findings in Afghanistan.15 The 2010 recommendations were critical but not implemented enough to obtain substantial results, and they need more investment and innovative approaches to be implemented holistically. SBAs’ knowledge and capacity should be improved through evidence-based and cost-effective capacity-building approaches, such as short, periodic, additional “skills and drills” sessions or “fire drills,” that have the potential to help ensure knowledge and skills are retained over time. After training, health care providers retain knowledge and skills only for up to 12 months.25
Although most facilities had supplies, equipment, and drugs needed for PAC, there were gaps in availability of supplies, equipment, and drugs in different HFs. More than two-thirds of HFs, both public and private, had a D&C kit, indicating that this procedure is still widely practiced in Afghanistan. Routine D&C is riskier and more painful for removal of retained products of conception; it is no longer recommended by WHO and should be phased out gradually.16
More than half of public and private HFs included in this study had misoprostol. On average, availability of misoprostol was higher at SHs, RHs, and PHs than other HFs. In Afghanistan, the PAC national standards and training package were updated in 2017. They authorized both MVA and misoprostol for managing complications of abortion, but misoprostol is not included on the Essential Medicines List for PAC. Recent evidence emphasizes that misoprostol should be available in a functioning and human rights-based health system as a core essential medicine.26 Studies show substantial promise to extend the option for treating incomplete abortion and miscarriage with misoprostol at the district and lower levels in remote, rural, and impoverished areas, where access to PAC and surgery is mostly restricted.11,13 Misoprostol is heat stable, relatively inexpensive, and easy to administer, and has yet to be demonstrated and effectively operationalized at mid- and lower-level facilities.27 Furthermore, there are many gaps in the literature on service delivery aspects of misoprostol, particularly for PAC, hindering efforts to institutionalize its more widespread safe, acceptable, and effective use, which needs rigorous advocacy and support at various levels.11 Programs should ensure that both MVA and misoprostol are available at HFs, and women should be informed of appropriate treatment options, staff should be trained, and communities should be informed.19
EmONC guidelines were available at fewer than half of public and private HFs. These guidelines indicate managing incomplete abortions and miscarriage using MVA as a signal function but lack the medical treatment of incomplete abortion and family planning component of PAC. It is important for health managers to ensure that the updated national standards and training package for PAC are available at HFs and describe revised practices that are important instruments for ensuring quality.9,19
Most of the facilities visited had a mix of short- and long-term contraceptive commodities available at the time of the assessment. Implants, which were only recently added to the MoPH Essential Medicines List, were not available in most of the HFs. Contraception and safe abortion care go hand in hand in the strategy to reduce unwanted pregnancies, unsafe abortions, and maternal deaths. Increasing access to modern contraception and timely provision of family planning services are essential components to reducing unmet need, unintended or unwanted pregnancies, and the abortions or unplanned births that often follow. Spacing between pregnancies is considered important for women’s and children’s health. After a miscarriage or an induced abortion, women should wait at least 6 months before becoming pregnant again.16,28
More than two-thirds of SBAs expressed the need for counseling on family planning for postabortion clients, while fewer than one-third expressed the need for information on social support, consequences of unsafe abortion, and infection prevention. Social norms and health care providers’ personal beliefs could be factors in the low levels of family planning counseling and method acceptance. Some factors that challenge the effective implementation of PAC programs include provider bias and/or resistance to provide family planning to postabortion clients due to abortion-related stigma and cultural barriers, and women who are disempowered to make decisions regarding contraceptive use.28 Studies show that women lacked the authority to make family planning decisions without involvement of men in some settings.29 In many societies, extreme pressure is placed on woman to bear sons, including in Afghanistan; they may encounter violence, abandonment, or stigma for birthing girls instead of boys. Therefore, engaging men and boys in the process of transforming attitudes around inequality in gender norms is critical.30
A study in Haiti denoted the importance of timely education on PAC and postabortion contraception, and involving women, men, and health care providers.31 There is also evidence that abortion clients are interested in receiving a modern method of contraception after their abortion if offered.17 Provision of counseling to women should be voluntary, confidential, and nondirective.9 Providers’ knowledge and counseling skills could be improved through evidence-based, short, repeated learning sessions.25,32 Respectful care is a key component of quality of care within a rights-based framework and should be considered while providing family planning counseling and services.33 It is paramount to consider values clarification exercises while developing the capacity of health care providers to ensure that women are treated with respect and to prevent negligence.28 Evidence suggests that high-quality counseling and availability of follow-up care can reduce rates of method discontinuation.33
This study also shows major gaps in documentation of postabortion cases at public and private HFs. Fewer than half of HFs had registers to track women with postabortion complications and those who were discharged with a contraception method. Documentation for PAC services could be further improved to capture information on postabortion clients receiving contraceptives by method before leaving the facility and at return visits,19 and the signs and symptoms of postabortion complications that would need medical attention.
Health management information systems should include and report the quality indicators for PAC services as an essential measure of program and provider performance and accountability.19 Constraints to accurately measure abortion levels have become more prevalent over the years where medical abortions, private-sector abortions, and the stigmatization of abortion have become more common, as these factors would increase the level of underreporting.10 Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including improving access to family planning services and the effectiveness of contraceptive use, and ensuring access to safe abortion services and PAC, are crucial steps toward achieving the Sustainable Development Goals.34
Although this study was not designed to provide a representative picture of private-sector HFs or directly compare public versus private HFs, a snapshot suggests that the private sector’s capacity to provide PAC services might be similar to the public sector’s.
This study had certain limitations. It was designed to assess the quality of broader maternal and newborn health services, so some critical aspects of PAC, such as providers' actual performance on the job, particularly how well they counsel and interact with patients, were not captured. The information on community mobilization and awareness, an important component of PAC, was not in the scope of this assessment. Although the assessment was national in scope, security concerns and seasonal conditions prevented data collection teams from visiting two high-volume HFs that met inclusion criteria and 39% of randomly selected low-volume facilities. Alternative facilities of the same type were randomly selected following approved replacement sampling procedures, but findings can only be generalized to accessible HFs, not all HFs, in Afghanistan. Data collection on health services was based on verbal information of facility managers, not documentation of services or actual triangulation of available data sources at various levels. The private-sector snapshot did not represent the overall picture of PAC in private HFs in Afghanistan and cannot be compared with nationally representative data from public HFs. There is a need for accurate, informative, and generalizable data on the capacity of private HFs that deliver high-quality PAC.
Despite these limitations, this study provides important information on the current capacity of the public and private health system in Afghanistan to deliver PAC, and offers insights to improve services to save women’s lives.