Postabortion care counseling practiced by health professionals in southeastern Nigeria

Postabortion care counseling practiced by health professionals in southeastern Nigeria

International Journal of Gynecology and Obstetrics 111 (2010) 53–56 Contents lists available at ScienceDirect International Journal of Gynecology an...

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International Journal of Gynecology and Obstetrics 111 (2010) 53–56

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Postabortion care counseling practiced by health professionals in southeastern Nigeria Joseph I. Adinma a, Lawrence Ikeako b, Echendu Dolly Adinma c,⁎, Chukwuemeka Ezeama a, Nkemakolam Eke a a b c

Department of Obstetrics and Gynecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital (Amaku), Awka, Nigeria Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria

a r t i c l e

i n f o

Article history: Received 22 December 2009 Received in revised form 27 May 2010 Accepted 29 June 2010 Keywords: Counseling Health professionals Postabortion care Southeastern Nigeria

a b s t r a c t Objective: To determine the practice of postabortion care (PAC) counseling among healthcare professionals in southeastern Nigeria. Methods: A cross-sectional questionnaire-based survey conducted among healthcare professionals in Anambra State, southeastern Nigeria, in 2006. Participants were chosen using a multi-stage sampling technique. A pre-tested questionnaire assessing the practice of PAC counseling was administered. Results: A total of 431 health professionals were questioned: 270 (62.6%) medical doctors and 161 (37.4%) nurses. Of 302 (70.1%) respondents who reported practicing PAC counseling, only 173 (40.1%) had received formal training. PAC counseling was most commonly practiced by health professionals working in the University Teaching Hospital (90.5%). It was also more commonly practiced by nurses in rural areas compared with nurses working in urban areas (75 [67.6%] vs 24 [48.0%]; P = 0.02). Conclusion: A high proportion of health professionals reported practicing PAC counseling. However, less than half had received formal training in PAC counseling. An increased PAC training activity program, with an emphasis on counseling, is recommended for health professionals to improve the overall quality of PAC service delivery. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction Maternal mortality is an index of the standard of a society's maternal health care. In high-resource countries, the quality of maternal health care has improved to such an extent that maternal mortality has virtually disappeared [1]. This is in contrast to the situation in low-resource countries, such as Nigeria, where maternal mortality is still alarmingly high [1]. Low-resource countries account for more than 99% of maternal deaths globally, with around 84% concentrated in Sub-Saharan Africa and South East Asia [2]. Nigeria has one of the highest maternal mortality ratios in the world, at 1100 per 100 000 live births [3,4]. It is estimated that unsafe abortion accounts for around 13% of maternal deaths globally [5]. More than 4 million abortions occur annually in Africa, with Nigeria accounting for about 760 000 procedures [6,7]. It has been reported that approximately 25 abortions occur per 1000 women aged 15–44 years in Nigeria [7]. A high proportion of women die from the complications of abortion, whether spontaneous or induced. Unsafe abortion is reported to be responsible for 36 000 maternal deaths annually in Nigeria. This figure represents ⁎ Corresponding author. Department of Community Medicine, Nnamdi Azikiwe University Teaching Hospital, P.M. B. 5025, Nnewi, Anambra State, Nigeria. Tel.: + 234 8033407384. E-mail address: [email protected] (E.D. Adinma).

over 50% of the maternal deaths that occur in Nigeria—an alarming figure when compared with global estimates of 13% [5,8]. In Nigeria, as in other parts of the world, women conceive pregnancies that may be unplanned. Faced with this situation, some women seek to terminate their pregnancies by safe methods; however, termination is often performed by whatever means are available. Only about 40% of women with an unplanned pregnancy will have an abortion performed by a physician in an established health facility, while nonphysician providers will perform the procedure for the remainder [9]. Consequently, most of these abortions are conducted by unskilled personnel under unhygienic and generally unsafe conditions, which put these women at risk for avoidable morbidity and mortality. Abortion law in Nigeria is restrictive: abortion is permitted only to save the life of a woman. Despite this legislation, abortions take place in high numbers in Nigeria under both safe and unsafe conditions. In countries that impose severe restrictions on abortion, women attempt to terminate unwanted pregnancies through clandestine means, with resultant complications. It is estimated that 142 000 women are treated annually for complications of abortion in Nigeria [10]. A nationally representative sample of facilities in Nigeria in the mid-1990 s estimated that 27% of women who received abortion care were seeking an abortion, 47% needed treatment for complications resulting from an attempted abortion, and 26% were treated for complications resulting from a spontaneous abortion [10]. A similar survey carried out in Nigeria in 2008 among women admitted to

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hospital for abortion-related complications showed that 36% had attempted to end the pregnancy before arriving at hospital (24% with serious complications and 12% without), 33% obtained an induced abortion at the facility without having made a prior abortion attempt, and 32% were treated for complications arising from a spontaneous abortion [10]. Complications of induced abortion have been reported to account for 12% of all gynecological admissions in Ile-Ife, Nigeria [11]. Clearly therefore, abortion and its related complications constitute a major reproductive health issue in Nigeria. In order to reduce the morbidity and mortality arising from unsafe abortion, Post Abortion Care (PAC) was initiated. This approach consists of a series of medical and related interventions designed to manage the complications of spontaneous and induced abortion, both safe and unsafe, and to improve women's reproductive rights and lives [12]. The PAC model consists of 5 elements: treatment of incomplete and unsafe abortion and abortion-related complications that are life threatening; counseling to respond to the physical and emotional needs of the woman, together with her other health concerns; contraceptive and family planning services; community and service provider partnerships; and linkages with other reproductive health services [12]. Effective counseling is an integral part of high-quality PAC. All women receiving PAC have the right to high-quality counseling. PAC counseling is structured so that the client voluntarily receives emotional support and guidance from a trained person in an environment that is conducive for openly sharing thoughts, feelings, and perceptions. Effective PAC counseling should take place before, during, and after the woman receives medical treatment, provided it does not subject the woman to undue treatment delays that may put her life at risk. The aim of the present study was to determine the practice of PAC counseling among health professionals in Anambra State, southeastern Nigeria, to elicit information to assist in the planning and development of group-specific PAC counseling training programs for more effective PAC service delivery. 2. Materials and methods We conducted a cross-sectional, questionnaire-based survey among healthcare professionals in Anambra State, southeastern Nigeria, between June 1 and September 30, 2006. Anambra State is one of 5 States in southeastern Nigeria and has a population of about 4 million. It harbors a homogeneous Igbo-speaking ethnic group of predominantly Christian religious denomination. The Igbo people represent one of 3 major Nigerian ethnic groups; the other groups are the Hausas of the north and the Yorubas of the southwest. A list of the registered health facilities providing maternal health services in Anambra State was obtained from the State Ministry of Health. These health facilities were categorized as primary, secondary, and tertiary. Primary healthcare centers and maternity homes managed by State-registered nurses and midwives were categorized as primary facilities; general hospitals, private general practice hospitals, and mission hospitals manned by nonspecialist doctors were categorized as secondary; and private specialist hospitals manned by specialists and the University Teaching Hospital were categorized as tertiary facilities. There were 80 primary health facilities, 1145 secondary, and 47 tertiary health facilities contained in the list. Using a simple random sampling technique, 20 health facilities were selected from each category, giving a total of 60 facilities. A nonproportional quota sampling technique was employed to select the doctors and staff nurse-midwives from the maternity unit of each selected health facility. Only health practitioners handling abortion cases were selected. A total of 431 health professionals were ultimately selected, comprising 45 from the primary category, 339 from the secondary category, and 47 from the tertiary category. The disparity in allocation of sample size—a high number skewed to the secondary category of health facilities—was borne out of the

experience in southeastern Nigeria, where women seeking abortion services in orthodox health facilities attend this category of health facility more commonly. The respondents were interviewed using pre-tested, structured, self-administered questionnaires to obtain information on their practice of PAC counseling. The questionnaire contained information on the sociodemographic characteristics of the respondents (age, sex, professional cadre, duration and location of practice); type of facility of practice; PAC counseling training status; and time of provision of PAC counseling. The obtained data were analyzed using Epi Info version 2000 (Centers for Disease Control and Prevention; Atlanta, GA, USA). Statistical relationships between variables were ascertained using the χ2 test. P b 0.05 was considered significant. Ethical clearance for the study was obtained from the Research Ethics Committee of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria; written informed consent was obtained from the participating healthcare professionals in the study.

3. Results A total of 431 health professionals were involved in the study: 230 (53.4%) males and 201 (46.6%) females. There were 270 (62.6%) medical doctors and 161 (37.4%) nurses. Table 1 shows the sociodemographic characteristics and practice of PAC counseling among the respondents. Mean age of the respondents was 38.2 ± 10.5 years (range, 20–61 years). The age range with the greatest proportion of professionals who practiced PAC counseling was 35–39 years (n= 40; 76.9%), followed closely by those within the 30– 34 years range (n = 32; 76.2%). There was no significant difference in PAC counseling practice between the male and female respondents (71.7% vs 68.2%; P = 0.42). The health cadre with the greatest proportion of its members performing PAC counseling was specialist doctors (n= 52; 94.5%); the lowest proportions were among resident doctors (n= 3, 60.0%) and nurses (n= 99; 61.5%). Overall, a significantly greater proportion of medical doctors performed PAC counseling compared with nurses (203 [75.2%] vs 99 [61.5%]; P = 0.003). The duration and location of practice according to provision of PAC counseling are shown in Table 2. There was no difference in PAC counseling practice between doctors who had practiced for more than 10 years compared with those who had practiced for under 10 years

Table 1 Sociodemographic characteristics and PAC practice of the health professionals surveyed (n = 431).a Characteristics

Total

Practiced PAC counseling Yes

Age, y 20–24 25–29 30–34 35–39 40–44 45–49 50–54 ≥55 Sex Male Female Cadre of health professional Specialist doctors Resident doctors GMP Nurses

X2

P value

0.66

0.42

9.02

0.003

No

25 101 42 52 92 55 24 40

(5.8) (23.4) (9.7) (12.1) (21.3) (12.8) (5.6) (9.3)

11 66 32 40 68 38 18 29

(44.0) (65.3) (76.2) (76.9) (73.1) (69.1) (75.0) (72.5)

14 35 10 12 24 17 6 11

(56.0) (34.7) (23.8) (23.1) (26.1) (30.9) (25.0) (27.5)

230 201

(53.4) (46.6)

165 137

(71.7) (68.2)

65 64

(28.3) (31.8)

55 5 210 161

(12.8) (1.1) (48.7) (37.4)

52 3 148 99

(94.5) (60.0) (70.5) (61.5)

3 2 62 62

(5.5) (40.0) (29.5) (38.5)

Abbreviation: PAC, postabortion care; GMP, General Medical Practitioner. a Values are given as number (percentage) unless otherwise indicated.

J.I. Adinma et al. / International Journal of Gynecology and Obstetrics 111 (2010) 53–56 Table 2 Duration and location of practice of the health professionals surveyed (n = 431).a Characteristics

Practiced PAC counseling Yes

Duration of practice, y Doctors ≤ 10 N 10 Nurses ≤ 10 N 10 No response Total Location of practice Doctors Urban Rural Nurses Urban Rural Total

Total

χ2

P value

84 118

(77.1) (73.8)

25 42

(22.9) (26.2)

109 160

0.38

0.54

48 47 5 302

(54.5) (74.6) (45.5) (70.1)

40 16 6 129

(45.5) (25.4) (54.5) (29.9)

88 63 11 431

6.33

0.01

84 119

(81.6) (71.3)

19 48

(18.4) (28.7)

103 167

3.62

0.06

24 75 302

(48.0) (67.6) (70.1)

26 36 129

(52.0) (32.4) (29.9)

50 111 431

5.57

0.02

Abbreviation: PAC, postabortion care. a Values are given as number (percentage) unless otherwise indicated.

Table 3 Type of facility of practice among health professionals surveyed (n = 431).a Practiced PAC counseling Yes University teaching hospital Private specialist hospital General hospital Voluntary agency/mission hospital Private general practice hospital Health center Maternity home Total

19 21 97 118 18 9 18 300

Total

No (90.5) (80.8) (68.3) (71.5) (56.5) (69.2) (56.3) (69.6)

2 5 45 47 14 4 14 131

(9.5) (19.2) (31.7) (28.5) (43.8) (30.8) (43.7) (30.4)

Abbreviation: PAC, postabortion care. a Values are given as number (percentage) unless otherwise indicated.

PAC counseling training status Doctors (n = 270) Trained Not trained No response Nurses (n = 161) Trained Not trained No response Time of provision of PAC counseling Doctors (n = 203) Before treatment During treatment After treatment Nurses (n = 99) Before treatment During treatment After treatment

No.

(%)

114 145 11

(42.2) (53.7) (4.1)

59 95 7

(36.7) (59.0) (4.3)

42 1 163

(20.7) (0.5) (80.3)

22 0 77

(22.2) (0.0) (77.8)

Abbreviation: PAC, postabortion care.

(118 [73.8%] vs 84 [77.1%]; P = 0.54). In contrast, among nurses there was a significant difference in PAC counseling practice between those who had practiced for more than 10 years compared with those who had practiced for under 10 years (47 [74.6%] vs 48 (54.5%); P = 0.01). There was also no difference in PAC counseling practice between doctors who practiced in rural compared with urban areas (119 [71.3%] vs 84 [81.6%]; P = 0.06). However, a significantly greater number of nurses practicing in rural areas carried out PAC counseling compared with those in urban areas (75 [67.6%] vs 24 [48.0%]; P = 0.02). Table 3 shows the respondents’ health facility of practice according to provision of PAC counseling. PAC counseling practice was highest among health professionals in the University Teaching Hospital (n = 19; 90.5%), followed closely by those in private specialist hospitals (n = 21; 80.8%); it was lowest among those working in private general practice hospitals (n = 18; 56.5%) and maternity homes (n = 18; 56.3%). PAC counseling training status and time of provision of PAC counseling are shown in Table 4. Of the 431 respondents, 173 (40.1%) had received formal training in PAC counseling: 114 (42.2%) medical doctors and 59 (36.7%) nurses. Of the 75 nurses from rural areas who practiced PAC counseling, 48 (64.0%) had received PAC training. In contrast, among 24 nurses from urban areas who practiced PAC counseling, 11 (45.8%) had received PAC training. In addition, among nurses who had practiced for more than 10 years, 38 (80.9%) of the 47 that practiced PAC counseling had been trained; among nurses who had practiced for 10 years or under, only 21 (43.8%) of the 48 who practiced PAC counseling had been trained. PAC counseling was carried out

Type of health facility

Table 4 PAC counseling training status and time of provision of PAC counseling among the health professionals surveyed. Variable

No

55

21 26 142 165 32 13 32 431

after treatment by the majority of medical doctors (n= 163; 80.3%) and nurses (n= 77; 77.8%). Provision of PAC counseling during treatment was practiced by 0.5% of medical doctors, while none of the nurses reported providing PAC counseling during treatment (Table 4). 4. Discussion PAC counseling is an important component of high-quality PAC services and is usually necessary to relieve the patient of both the psychological and physical trauma often associated with abortion, as well as providing information on female reproductive health issues. The present study shows that a high proportion of respondents reported practicing PAC counseling in Nigeria, among both doctors and nurses. This is in contrast to other studies conducted in Nigeria that revealed a poor "practice" of PAC services among healthcare providers [13,14]. Effective counseling comprises issues related to the management of abortion, such as pain relief and infection treatment, as well as those related to future reproductive health concerns, notably contraception and management of infertility. Counseling on HIV/AIDS, for example, is particularly important because women who have had an abortion may be at risk for unprotected sex and might unknowingly be HIV positive. In South Africa, a study found that just over 50% of postabortion patients were given information about HIV and STIs [15]. Similarly, some studies conducted in other parts of Africa have shown that integrating contraceptive counseling into PAC is an effective approach, which results in an increased use of contraceptive services in both the short and long term [16–19]. The practice of PAC counseling among medical doctors in the present study was high among specialists compared with resident doctors and general medical practitioners. This is not surprising, considering the standards expected of specialists. Furthermore, training on PAC is not typically included in the undergraduate medical curriculum and the graduating medical practitioner is usually poorly informed about PAC services. Therefore, it has become absolutely necessary that every medical practitioner undergoing the preregistration housemanship training rotation in obstetrics and gynecology should be trained in PAC services, including PAC counseling. In general, PAC counseling practice in the present study was found to be higher among medical doctors than nurses, which is most likely the result of the high number of specialists practicing PAC counseling. The influence of the duration and location of practice of PAC counseling provides an interesting picture among the nurses surveyed. PAC counseling was carried out by a greater number of

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nurses practicing in rural areas and among those who had practiced for more than 10 years. The reason for this is not clear considering that all nurses had received the same level of education (staff nursemidwives). It is possible that nurses working in urban centers—in hospitals with specialist doctors—may not have the opportunity to practice PAC counseling; in contrast, nurses practicing in rural areas are often the sole health professionals in health centers and, therefore, are likely to be responsible for PAC counseling. Regarding duration of practice, this may be related to the typical protocol of nominating nurses for training on the basis of their seniority in service. Therefore, nurses who have practiced for more than 10 years are more likely to be exposed to PAC training than those whose practice is less than 10 years. In the present study, 80.9% of nurses who had practiced for more than 10 years and who practiced PAC counseling had been trained, whereas 43.8% of nurses who had practiced for less than 10 years had received training. PAC counseling was also practiced most commonly by health professionals working in tertiary healthcare facilities. This is expected as these health professionals have easy access to recent information and training. Only 173 (40.1%) respondents in the present study had received formal training in PAC counseling. This figure is low compared with the relatively high number (70.2%) of respondents who reported practicing PAC counseling, which may cast doubt on the effectiveness of the counseling claimed to be practiced. The relatively low number of health professionals with formal training in PAC counseling may account for the low levels of pretreatment and during treatment counseling reported. The present study reveals a reasonably high level of practice of PAC counseling among health professionals in southeastern Nigeria. However, less than 50% of professionals reported having received any formal training in PAC counseling. Undoubtedly, this is likely to reduce the overall quality and effectiveness of the counseling rendered. It is recommended that increased PAC training activities with emphasis on counseling are conducted among all cadres of health professionals in Nigeria to improve the overall effectiveness of PAC counseling. Conflict of interest The authors have no conflicts of interest to disclose.

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