training quality of care referral networks postabortion contraception and counseling Scaling Up Access to High-Quality Postabortion Care in Kenya:

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1 referral networks Scaling Up Access to High-Quality Postabortion Care in Kenya: An Assessment of Public and Private Facilities in Western and Nyanza Provinces Sarah Onyango, Ellen Mitchell, Nancy Nyaga, Katherine Turner, Roxane Lovell Ipas quality of care training postabortion contraception and counseling

2 Ipas Ipas works globally to increase women's ability to exercise their sexual and reproductive rights and to reduce abortion-related deaths and injuries.we seek to expand the availability, quality and sustainability of abortion and related reproductive-health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or health because she lacks safe reproductive-health choices. For more information on Ipas products, programs and publications: Ipas 300 Market Street Suite 200 Chapel Hill, NC USA For more information on Ipas s work in Africa: Ipas Africa Alliance 1st Floor, FAWE House Chania Avenue P.O. Box City Square Nairobi, Kenya phone: fax: info@ipas.or.ke Copyright 2003 Ipas. This publication may be reproduced in whole or in part, without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged. ISBN: Suggested citation: Sarah Onyango, Ellen Mitchell, Nancy Nyaga, Katherine Turner and Roxane Lovell Scaling up access to high-quality postabortion care in Kenya: A facility-based assessment of public- and private-sector facilities in Western and Nyanza Provinces. Chapel Hill, NC, Ipas. Produced in the United States of America

3 Scaling Up Access to High-Quality Postabortion Care in Kenya: An Assessment of Public and Private Facilities in Western and Nyanza Provinces Sarah Onyango Ellen Mitchell Nancy Nyaga Katherine Turner Roxane Lovell Ipas

4 Acknowledgments Siaya Butere-Mumias Busia Kisumu Bondo Kakamega We wish to acknowledge Dr. Josephine Kibaru (Head of the Division of Reproductive Health, Ministry of Health) and her deputy Dr. M.M. Solomon, Dr. Robert Ayisi, (Provincial Medical officer of Health,Western Province), Dr. Ambrose Misore (Provincial Medical officer of Health), Nyanza Province and the District Health Management Teams of the six districts for supporting these efforts wholeheartedly. A special thank you to the data collectors District Public Health Nurses (DPHN) and Students Francis A. Magak - DPHN Siaya Jairus Songa - DPHN Butere Mumias Elizabeth Apopo - DPHN Busia Iscah Akello - DPHN Kisumu Charles Okerosi - DPHN Bondo Japheth Kubati - DPHN Kakamega Hannington Onyango - Research Assistant Onesmus Mlewa - Research Assistant Zephania Kamau Maina - Research Assistant Mary Waithira Gichuhi - Research Assistant Aflonia Mbuthia - Research Assistant Our sincere thanks to Janet Masi and Ellen Vaz for their roles in data entry. We especially thank Livia Montana from MACRO and the National Council on Population and Development for sharing the raw data from the 1999 Kenya Service Provision Assessment. Thanks to Edward S. Cherry for developing the maps used in this report.we are grateful to the United Nations Food and Agriculture Organisation for providing the boundary lines and meta data necessary to create the maps. We acknowledge the work of Maribel Mañibo in formatting the survey tools, and Sarah Packer for administrative assistance on revisions.we thank Marty Jarrell, Valerie Holbert and Diana Kowal Robinson for contributing invaluable editorial and graphical expertise. Janie Benson, Hailemichael Gebreselassie and Charlotte Hord Smith provided comprehensive technical critique and invaluable input in the organisation and juxtaposition of findings. The Maendeleo ya Wanawake organization played a pivotal role in the development of the intervention and in the work in this region.we would like especially to thank Dorcas Amolo (Program Officer) and Louise Sewe (Trainer) for spearheading the community activities. We also acknowledge the financial contributions of the United Kingdom Department for International Development. 2

5 Table of Contents List of Tables and Figures Executive Summary Introduction Study Context Study Methods Sample Selection Sample Characteristics Data Collection Analysis Study Limitations Results Access to PAC in the Region PAC Caseloads Use of MVA Technology Cost of PAC Services Facility Infrastructure for PAC Essential Drugs and Infection Prevention Human Resources and Training in PAC Postabortion Family Planning HIV Prevention Capacity Quality of Existing PAC Services Community Involvement Scale-up Intervention Conclusion References

6 List of Tables & Figures Table 1 Table 2 Table 3 Table 4 Table 5 Figure 1 Table 6 Table 7 Figure 2 Table 8 Table 9 Figure 3 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Table 16 Table 17 Table 18 Table 19 Table 20 Table 21 Table 22 Table 23 Table 24 Comparison of Selected Indicators of Women s Power & Agency Comparison of Reproductive Characteristics of Women in Nyanza and Western Population and Facility Sample by Intervention Districts (n=120) Comparison of Universe and Recruited Sample by Level Study Sample by Level and Affiliation Geographic Dispersion of the Sampled Facilities Data Collection Instruments, Methodologies and Topic Areas Administrators Report of Facility Provision of PAC by Province and Affiliation Availability of Elements of PAC by Level (n=108) Comparison of PAC Access in Two Facility Surveys in Western & Nyanza Availability of Specific Evacuation Techniques Among PAC Facilities by Affiliation Comparison of Aggregate Incomplete Abortion Caseloads by Affiliation Comparison of Mean Caseloads for a 90 Day Period by Level Comparison of Mean Caseloads for a 90 Day Period by Affiliation Comparison of Median Cost in Kenyan Shillings of Uterine Evacuation by Sector (n=41) Proportion of Facilities with Stocks of Essential Drugs to Treat Complications of Abortion by Affiliation Proportion of Facilities with Stocks of Essential Drugs to Treat Complications of Abortion by Level Proportion of Facilities with Stocks of Pain Management Medications by Affiliation Proportion of Facilities with Stocks of Pain Management Medications by Level Percentage of Facilities with Instrument Processing and Infection Prevention Equipment by Affiliation Percentage of Facilities with Instrument Processing and Infection Prevention Equipment by Level Percentage of Facilities with Infection Prevention Supplies by Affiliation and Province Percentage of Facilities with Infection Prevention Supplies by Level Percentage of Facilities with General-Purpose Equipment by Affiliation Percentage of Facilities with General-Purpose Equipment by Level Percentage of Facilities with Selected Functional Gynaecology Instruments by Affiliation Percentage of Facilities with Selected Functional Gynaecology Instruments by Level 4

7 Table 25 Table 26 Table 27 Table 28 Table 29 Table 30 Table 31 Table 32 Figure 4 Table 33 Table 34 Table 35 Table 36 Table 37 Table 38 Table 39 Table 40 Table 41 Table 42 Table 43 Table 44 Table 45 Table 46 Table 47 Table 48 Table 49 Percentage of Facilities with Functional Intravenous (IV) equipment and Supplies by Affiliation Percentage of Facilities with Functional Intravenous (IV) Equipment and Supplies by Level Percentage of Facilities with Essential Furniture in Functional Condition by Affiliation Percentage of Facilities with Essential Furniture in Functional Condition by Level MVA Technology in Facilities by Data Collection Method Physician Staffing in All Facilities by Cadre Comparison of Physician Prevalence in PAC Versus Non-PAC Facilities Comparison of Presence of One or More Midlevel Staff in Facilities by Level Comparison of Staffing by Cadres in PAC Versus Non-PAC Facilities Proportion of Facilities with Midlevel Providers Eligible to Provide Uterine Evacuation with MVA Prior Formal PAC Training Among Clinicians (By Cadre) Prior Formal PAC Training Among Nurses (By Cadre) Percentage of Facilities Stocking Specific Family-Planning Methods by Affiliation Percentage of Facilities Stocking Specific Family-Planning Methods by Level Percentage of Facilities Offering Long-term Clinical Methods of Family Planning by Affiliation Percentage of Facilities Offering Long-term Clinical Methods of Family Planning by Level Completeness of Case Records by Nine Diagnostic and Treatment Indicators Self-Reported Referral Behaviours in Facilities without PAC (n=67) A Comparison of Transport Capacity of Facilities Between PAC and Non-PAC Facilities Comparison of Waiting Periods for MVA by Information Source and Operating Institution Comparison of Waiting Periods for Sharp Curettage by Information Source and Operating Institution Pain Management Strategies Recorded in Patient Records Comparison of Sample with Sites Selected for Intervention Comparison Between Total Study Sample and Selected Intervention Sites by Level Comparison Between PAC Study Sites and Selected Intervention Sites by Level Scale Up Objectives and Benchmarks 5

8 Executive Summary This report offers an in-depth look at postabortion care (PAC), both in its availability and the potential to expand PAC in six districts in Western and Nyanza Provinces in Kenya. This report is based on a multi-method facility assessment conducted in November 2002 as well as a survey of community members from Maendeleo ya Wanawake, Kenya s largest women s organization.we measured the quality of PAC in a representative sample of forty-one public, private and missionaffiliated facilities, as well as the capacity for introducing PAC into sixty-seven additional facilities.this project covers multiple levels of the health system, with particular emphasis on the primary and secondary levels of care. The overall goals of the study were: 1. to provide information on the current status of PAC, including the quality of care in two provinces in Kenya; 2. to determine facilities infrastructure, equipment, supplies and staffing capacity for introducing PAC services where these services do not exist; 3. to identify eligible cadres of health workers for training in PAC. Specifically, the facility assessment attempted to answer the following questions: Where and when are services available? What are patients paying for PAC services? Who provides services? What is the quality of the services? What training is needed? What essential equipment is needed? What are potential providers attitudes toward the introduction of new PAC services? What are the outreach activities in the community? The survey of members of Maendeleo ya Wanawake inquired: How serious of a problem is abortion in the community? Where do community members assume PAC services are available? 6

9 What is community members assessment of the quality of available services? Although much of the data presented here build on over a decade of work in PAC in Kenya and confirm prevailing wisdom from experts in the field, several findings are noteworthy: At the secondary and tertiary levels, PAC is currently offered at 25 facilities (73.5%). At the primary level, PAC is much more limited, with less than half of nursing homes (47.1%) 1 and only 14.0% of health centres offering any services. Despite the historic emphasis on implementing manual vacuum aspiration (MVA) in higher-level facilities, a lower than expected proportion of hospitals (55.9%) offer MVA for postabortion uterine evacuation procedures. The availability of MVA varies dramatically among operating institutions. Whereas 94.7% of public PAC facilities offer MVA, only 53.3% of private and 57.1% mission-run sites offer MVA. Outside the public sector, MVA use is modest. Private facilities are less likely to treat with MVA. Further inquiry into the barriers to MVA use in the private sector will be important. In general, PAC facilities have access to the diagnostic and treatment equipment and supplies they need to provide high-quality PAC. However, implementation of PAC at the health-centre level will require acquisition of disinfecting equipment, manual vacuum aspirators, and functional gynaecological diagnostic tools (tenacula, specula) before they can provide PAC. Abortion caseloads appear to be lower than anticipated. Seventy-five percent of facilities manage less than seven cases per month.the relatively low number of abortion and PAC cases seen in facilities may be a consequence of access barriers, the presence of alternative community providers, or poor record keeping. This requires further investigation. Although there are few non-hospitals/primary-level facilities (nursing homes, health centres) offering PAC, those that do offer the treatment manage higher caseloads, on average, than hospitals. The mean cost to patients of sharp curettage was 3,976 Kenya Shilling (K Sh) (US dollar (USD) 51.63), whereas the mean cost of MVA was reported as 2,063 K Sh (26.79 USD). Costs to consumers in the private sector are four times those of the public sector. 1 Nursing homes are health facilities with inpatient beds and a level of medical attention that typically exceeds health centres, but is more limited than hospitals.there is not a standard definition of nursing home. 7

10 Contrary to conventional wisdom, the private sector is the largest provider of PAC services (average ±20/month), managing more than half of the case load in Western and Nyanza. This baseline hints at a significant evolution in the practice of uterine evacuation. Simple uterine evacuation with MVA is almost entirely entrusted to cadres of midlevel providers in both the public and private sectors. In this study, nurses were the most commonly cited providers of MVA, followed closely by clinical officers. These two professional groups manage over two-thirds of the documented MVA procedures. Even where PAC services are established, in almost half of PAC sites (43%) there is only one person formally trained in MVA. While informal skill transfer is a promising development, the quality of skills obtained merits further exploration. Improvements in record keeping are needed in order to assure quality of patient care. Data on quality of services, which could have provided important information for intervention design, were difficult to obtain because crucial information was not recorded in patient records. Despite the widespread use of MVA and the clinicians claim that service was provided in a timely manner, in fact many services are neither ambulatory nor timely. Patients experience delays both in receiving postabortion care and unnecessary delays in discharge. This increases facility costs while decreasing patient satisfaction. Although barrier methods (condoms) are now widely available, two-thirds of health centres and mission facilities lack stocks of popular family-planning methods, particularly injectables and progestin-only pills. The ability to prevent repeat abortions depends upon the facility s ability to meet women s family-planning needs. Maendeleo ya Wanawake members appreciate the scope and severity of the unsafe abortion problem in Western and Nyanza provinces, however they are often unaware of the location of PAC and refer patients to local health centres where PAC is generally unavailable. Information from this report has been used to plan for new PAC services in twenty-eight facilities, while strengthening existing services through the training of additional providers and improving access to equipment. A follow-up assessment is planned for 2004 to measure the expansion and improvement in PAC services. 8

11 Introduction Since independence in 1963, Kenya has achieved major milestones in health indicators, including reductions in the total fertility rate (TFR) and increased contraceptive availability. Despite this progress, Kenya faces an elevated national maternal mortality ratio (MMR) of 1,300 per 100,000 live births (Daulaire et al., 2002) and each year, over 3,000 women of reproductive age die of complications from unintended pregnancies and over half a million more suffer short- and longterm morbidity (Daulaire et al., 2002). An estimated 30 50% of these complications are a direct result of unsafe abortion (Solo et al., 1998). Many induced abortions are performed by untrained persons using a variety of unsafe procedures (Bohmer et al., 2002). These abortions frequently lead to haemorrhage, sepsis and other complications. In many cases, women do not receive appropriate or timely emergency treatment and die from treatable conditions. Over a decade ago, hospital-based studies in Nairobi showed that unsafe abortion accounted for as much as 35% of maternal mortality and over half of hospital gynaecological admissions (Lema et al., 1989; Rogo, 1993). Although it is now suggested that severe abortion-related morbidity in Kenya has fallen in response to concerted efforts on the part of the Ministry of Health (MOH) and nongovernmental organizations (NGOs), this assertion is based on descriptive studies in the large metropolitan referral hospitals (Cobb et al., 2001). In 2002,The National Magnitude of Unsafe Abortion Study a survey of referrals from provincial and district-level facilities found that while simple cases of incomplete abortion were treated in a timely and appropriate fashion, the rate of maternal morbidity remained unacceptably high (Onyango and Gebreselassie, 2003).According to the study, almost one in five postabortion patients arrive at hospital in critical condition, almost 30% of patients exhibit signs of infection and almost one in ten present with organ failure. For health facilities to derive the full benefit of ambulatory care with MVA and postabortion contraception, an appropriate policy framework is needed. The current Penal Code of Kenya restricts abortion in most cases. Termination of pregnancy is permitted to preserve the life of the woman and a person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon any person for his benefit, or upon an unborn child for the preservation of the mother s life, if the performance of the operation is reasonable, having regard to the patient s state at the time and to all the circumstances of the case (Penal Code, Section 240). Some have interpreted this section to also include the preservation of the woman s mental or physical health based on the English Abortion Act of 1967 (CRLP, 1997). Even where abortion would be permitted under the current law, numerous barriers to safe, elective abortion services exist. 9

12 Over the last 15 years, the Kenyan MOH has worked to improve the quality and availability of PAC services through provider training, changes in the clinical management of incomplete abortion, linkage of treatment services to family-planning counselling, and decentralization of services from tertiary-level hospitals to district hospitals. 2 Despite the on-going decentralization of PAC, there are still legal, economic, and social barriers that lead women to delay seeking treatment. Lifethreatening abortion complications remain a disproportionate share of the total abortion caseload. The Maternal Health Study a meta analysis of global progress on vital services conducted by The Futures Group found that vacuum aspiration, an essential obstetric emergency procedure, was the least available service in Kenyan health centres and district hospitals (Ross, 2002). This study also found significant disparities between rural and urban women s access to treatment for abortion complications. One key finding of the MOH s 1999 Kenya Service Provision Assessment (KSPA) was that despite prioritisation of PAC in the 1997 National Reproductive Health Strategy, achievements had been modest (1999:xvii) 3 and plans to decentralize PAC to health centres and empower nurses to perform PAC were still nascent (Kogi-Makau and Solo, 2000).The MOH acknowledges the problem of unsafe abortion and is prepared to address it.while the USAID strategic plan for Kenya calls for a modest increase from 44 Kenyan PAC facilities in 1999 to a target of 144 in 2005, the MOH of Kenya has adopted a more comprehensive approach. The MOH acknowledges that the problem of unsafe abortion should include a review of abortion legislation from the perspective of public health. In December 2001, the MOH finalized a draft report entitled Review and Harmonization of Health and Health-related Laws of Kenya. The First National Congress on Quality Improvement in Healthcare, Medical Research and Traditional Medicine, the main consultative forum with stakeholders, was held on 15 November 2001.These stakeholders identified the abortion law as one that merits further scrutiny. Many public-health advocates are calling for the repeal of the law. Even if this were to happen, there is consensus that existing physical facilities are neither adequate, nor are they accessible and publicized, not to mention that the country 2 The 1997 National Strategy for Reproductive Health Care incorporates the goal of the Safe Motherhood Initiative to reduce maternal morbidity and mortality and pays particular attention to the need to prevent unwanted pregnancy and strengthen facilities at the appropriate levels for the management of complications of unsafe abortion. Policies regarding the provision of PAC services are further specified in the 1997 Reproductive Health and Family Planning Policy Guidelines and Standards for Service Providers, which address the purpose of providing PAC emergency treatment and postabortion family planning. 3 KSPA is a 1999 USAID-sponsored nationally representative survey of health facilities that measures both reproductive health-care offerings as well as some facets of quality of care. 10

13 does not have sufficient trained personnel to deal with all matters and issues relating to reproductive health. The MOH is proposing a multi-pronged approach to address the abortion problem, namely: explore how public health is effected by current law; encourage new, sustainable postabortion services through training and re-engineering of public, private and mission facilities; equip new services with essential equipment for abortion and PAC. Ipas, at the request of the MOH, presented a proposal to spearhead the second element of this strategy. The present baseline study reports the conditions at service-delivery points as well as the attitudes of community members to guide the design and implementation of improvements in PAC. Essential Elements of PAC Community and service provider partnerships: Prevent unwanted pregnancies and unsafe abortion Mobilize resources to help women receive appropriate and timely care for complications from abortion Ensure that health services reflect and meet community expectations and needs Counselling: Identify and respond to women s emotional and physical health needs and other concerns Treatment: Treat incomplete and unsafe abortion and potentially life-threatening complications Contraceptive and family-planning services: Help women prevent an unwanted pregnancy or practice birth spacing Reproductive and other health services: Preferably provide on-site, or refer to other accessible facilities in providers networks PAC Consortium, 2002 In 2003, the Kenyan Minister of Health, Charity Ngilu, noted that, reproductive health is a human rights issue and women should be enabled to access reproductive health services and be free to make reproductive health decisions which impact on their health like spacing children, timing pregnancies and screening of cancers. (Mulama, 2003). 11

14 Study Context Despite progress in several regions, there are still barriers to PAC in Western Kenya.The six districts in this study comprise the area north of Lake Victoria.The 1999 Population and Housing Census reported that these districts are home to a population of more than 2.6 million people. Ethnically, Nyanza is primarily Luo around the lowlands nearest the lake. Western Province is predominately occupied by Bantu-speaking Luyha. There are also communities of Kalenjin speakers. Nyanza province is largely agricultural and densely populated, made up of 11 districts, namely: Kisumu, Siaya, Kisii, Homa Bay, Rachuonyo, Migori, Suba, Gucha, Nyamira, Bondo and Nyando.Western Province borders Rift Valley Province to the north, Nyanza Province to the South and the Republic of Uganda to the West. Western Province is divided into 8 administrative districts: Kakamega, Bungoma, Busia,Teso,Vihiga, Butere-Mumias, Lugari and Mt. Elgon districts. Beyond ethnic differences and access to health care, a large number of contextual factors influence women s use of family planning and prevention of unwanted or mistimed pregnancies. These include women s education, power within relationships, access to information through mass media, and access to household financial resources. Table 1 provides provincial comparisons of women s status from the 1998 Kenya Demographic and Health Survey. Table 1: Comparison of Selected Indicators of Women s Power & Agency Percentage of Women Nyanza Western Kenyan Average with less than primary education who are self-employed and earn cash who report decision-making authority over her cash earnings who have no access to mass media (Source: DHS, 1999) Table 2: Comparison of Reproductive Characteristics of Women in Nyanza and Western Nyanza Western Kenyan Average Median age at sexual debut Total fertility rate Ideal fertility rate Current use of modern contraception (%) Unmet need for family planning (%) (Source: DHS, 1999) 12

15 As Tables 1 and 2 show, women from Nyanza are at higher risk for unwanted pregnancy than their Kenyan peers in other provinces.women of Nyanza report the earliest median age of sexual debut in the nation (15.6 years old) and the highest school drop-out rates, leading to a significant proportion of women with less than a primary school education (57.9%). Women in Nyanza are also least likely to have access to any form of mass media and are therefore less able to receive public-health messages. Despite these barriers, women report higher than average decision-making authority over the allocation of their own incomes that can be a potent predictor of maternal health (World Bank, 1993). Women in Western Province are more representative of the nation as a whole, with 10% greater primary school completion and a median age of sexual debut that is two years later than peers from Nyanza (17.5 years old). Women from Western Province report greater media exposure, yet women in Western Province report the highest unmet need for family planning in the nation (32.4%) and the nation s highest fertility rate (5.6). The gap between women s desired and actual numbers of pregnancies (shown in Table 2) coupled with the restrictive legal environment for abortion create the social and economic conditions under which unsafe abortions will occur and access to high-quality PAC services becomes imperative. Studies exploring the social, economic and cultural impact of unsafe abortion in Siaya and Kisumu have highlighted the importance of PAC expansion to the health-centre level (Rogo et al., 1999; Cobb et al., 2001). 13

16 Study Methods Sample Selection On the basis of site visits, key informant interviews, and knowledge of prior interventions by partners and cooperating agencies, the Provincial Medical Officers (PMO) of Nyanza and Western Provinces and Ipas intentionally selected six underserved health districts as the intervention area. 4 District selection criteria were: a) under-served population b) absent or fragile PAC services c) high level of commitment from the District Health Management Teams d) presence of a well established community partner: Maendeleo ya Wanawake Organization Siaya Bondo Kisumu WESTERN NYANZA Busia Butere-Mumias Kakamega 4 Prior PAC training by KMET, FPIA, EngenderHealth, Christian Health Association of Kenya, PRIME, Ipas and AMKENI had led to improved coverage in Bungoma,Vihiga, Lugulu, Maseno, Kisii, Nyamira, Suba, Migori, R Onyo and Kehancha. 14

17 Sample Characteristics Once the study districts were identified, the MOH provided a list of the universe of the 120 public and private primary-, secondary- and tertiary-level facilities. 5 Table 3 shows the distribution of the universe of facilities by district and affiliation (n=120). Province Intervention 1999 Hospitals Nursing Health Total Districts Population Homes Centres Facilities Nyanza Kisumu 504, Siaya 480, Bondo 238, Western Busia 370, Butere/Mumias 476, Kakamega 603, AREA TOTALS Table 3: Population and Facility Sample by Intervention Districts (n=120) In all, 108 out of 120 facilities were recruited into the sample a sampling proportion of 90%. There were some minor differences between MOH site classifications and the facilities self-classification.the MOH recognizes only 17 facilities as hospitals, whereas in our survey 34 facilities claim hospital status, so the sampling proportions for hospitals and maternity/nursing homes are combined to adjust for this discrepancy. Universe BaselineSample Percentage of (n=120) (n=108) universe recruited Hospitals/Maternity/ Nursing homes Health centres Table 4: Comparison of Universe and Recruited Sample by Level The study sample is actually a census of public facilities (excluding dispensaries) in the districts, and findings are therefore broadly representative of conditions in the public sector and not as representative of the dynamic private sector. We opted 5 Due to the limited physical capacity for PAC service delivery, only one dispensary was included. For the purposes of this study, we group this dispensary among the health centres. 15

18 to recruit a purposive sample of the more established private sites.this was intentional, as inclusion of the larger, more permanent private facilities was considered more likely to identify potential sites for the introduction of PAC services, an explicit objective of this baseline assessment. Thus, caution is advised when generalizing conclusions to the entire private sector. Table 5: Study Sample by Level and Affiliation Total Public Mission Other Private Hospital Maternity/ Nursing home Health centre Nyanza Western The distribution of facilities by level and affiliations reflect their relative presence in the community. Facilities are equally distributed between the two provinces. As Table 5 shows, the Kenyan government runs most health centres, whereas maternity and nursing homes are exclusively mission affiliated or privately run. By contrast, all three types of organizations operate hospitals. As Figure 1 suggests, there are a greater number of facilities in the highly populated districts of Kakamega and Kisumu. Figure 1: Geographic Dispersion of the Sampled Facilities Kakmega 23% Butere- Mumias 17% Kisumu 23% Siaya 15% Busia 15% Bondo 7% 16

19 Data Collection The baseline survey was conducted during the course of one day per facility throughout the month of November A comprehensive survey instrument was developed and pre-tested by a team of clinicians, researchers and trainers. Using the six main instruments shown in Table 6, the data collectors gathered information on multiple aspects of PAC service delivery. Using an Administrator Questionnaire,key informants were intentionally selected and interviewed on operating policies and procedures of the facility. Often as part of the interview, a Staffing Assessment Tool measured the current human resources involved in PAC services, as well as potential candidates for training. Individuals in charge of stock rooms and equipment were queried using a Facility Inventory Questionnaire to identify equipment gaps and logistical barriers to implementing PAC.To measure the characteristics of clinical practice, key informants were purposefully selected for Clinician Interviews regarding their current practices, their attitudes toward PAC and MVA technology, where PAC is offered, and the various legal, cultural and organizational challenges to providing PAC. To measure the volume of PAC cases at each of the 41 facilities with PAC services, Log Books were scrutinized for the ninety-day period preceding the site visit. To assess both the record-keeping capacity of the site, as well as key indicators of clinical quality of care, Medical Chart Review was conducted of eight randomly-selected PAC case records per facility. Quality of service delivery was only measured in the 41 facilities where PAC was offered. 17

20 Table 6: Data Collection Instruments, Methodologies and Topic Areas Instrument Respondent/observer Main topics Interview Facility administrator Facility characteristics questionnaire Services offered Operating logistics Cost sharing Referral protocols Supplies, Supplies officer, MVA supplies & logistics infrastructure pharmacist, nursing or Basic furniture & tools and logistics clinical officer in charge Gynecology equipment instrument Consumables Observation/interview Infection prevention supplies Contraceptive methods availability Blood transfusion equipment Emergency equipment Essential drugs Staff Human resource Staffing profile Assessment administrator Prior provision of PAC training Clinician Clinician either: Caseloads Interview Provider of Treatment protocols PAC services or Treatment guidelines Potential PAC Treatment delays provider Quality control Treatment logistics Instrument processing Adolescent patient protocols Attitudes toward PAC Attitudes toward MVA for PAC Community outreach and referral Log Book Review Desk exercise Statistician Caseload Procedure mix Medical Chart Systematic random Quality of record keeping Review sampling Diagnostic techniques Statistician Patient profile Pain management strategies Complications 18

21 Pre-tests were conducted in three facilities (public and private) that were subsequently excluded from the study to identify and correct flaws in the questionnaire design or to adjust the administration of the questionnaire. A total of 11 data collectors, 6 District Public Health Nurses (DPHN) and 5 research assistants were selected and trained in survey techniques over a two-day period. Training conveyed the aims, objectives, techniques and terminology used in the study. Data collectors learned the thematic and questionnaire content, honed their interview skills through role-playing, and practiced protocols for protection of human subjects. The use of public-sector employees (i.e. insiders ) for the study of quality and availability of services has advantages in terms of acceptability and cost, however there may be disadvantages in terms of objectivity. One of the common risks of using stakeholders as data collectors is courtesy bias, wherein respondents tend to report to the stakeholders a higher level of satisfaction with the services and resources than the respondents actually perceive. There is a smaller chance for bias when using impartial outsiders (Campbell et al., 1999), but despite the risk, the pragmatic benefits of having DPHN data collectors outweighed the potential bias. Triangulation techniques were built into the survey design to permit verification of information susceptible to courtesy bias. All participation by informants was voluntary and uncompensated. Data collectors sought verbal consent prior to interview. While facility gatekeepers overall response to the survey was positive, there was some hesitation expressed among a small number of private-sector providers. The facility recruitment rate was 85-95% and within facilities, the consent rate of clinicians and administrators was 100%. MOH cooperation was central to the success of the data collection and the high recruitment rate may be attributable to the support for the PAC initiative expressed by facility administrators and Ministry officials alike. In addition to the facility baseline, a low literacy written survey was administered to 202 members of Mandeleo ya Wanawake, Kenya s largest women s organization, prior to an introductory course in PAC.The instrument measured their knowledge and attitudes toward women experiencing abortion and the facilities that treat them. 19

22 Analysis The facility and MYWO surveys were cleaned and entered into EPI-INFO Descriptive frequencies and cross-tabulations were generated using SPSS Study Limitations While the data are rich, certain constraints limit the depth and breadth of the study, and should be kept in mind. The study design originally included PAC patient exit-interviews. Interviews were intended to measure the clients satisfaction with PAC services, adequacy of postabortion contraceptive provision, patient costs, and referrals for other reproductive- and sexual-health needs. However, due to the low caseloads in many facilities and the data collection timeline, only 3 patients could be recruited within the facilities. As a result, we were unable to report on patient satisfaction or facilities effectiveness in meeting the pain-management, family-planning, HIV, or referral needs of PAC patients. Nor was it possible to derive conclusions about the quality of provider-client interaction. Where possible, information on these important elements is inferred from some proxy measures. Finally, the study design included the review of a systematic random sample of 8 client records at each of the 41 facilities offering PAC. However, the data audit revealed poor record keeping in the health facilities, resulting in missing or incomplete case records.therefore, conclusions are based on only 142 records from 30 facilities, instead of the anticipated 328 cases from 41 facilities. Reviewing cases only from facilities with adequate records tends to yield overestimates of the quality of services.all inferences drawn about the number of procedures, propriety of diagnostic and therapeutic techniques, adequacy of pain management strategies, and volume of complications experienced in the PAC facilities described in this report should be interpreted with extreme caution.this highlights the need for immediate intervention to improve both logbook and clinical record keeping in PAC facilities. 20

23 Results In the sections that follow, the major findings are presented thematically. For comparative purposes, data are grouped according to operating institution or affiliation (public, mission, private) and level of complexity (hospital, nursing home, health centre). Access to PAC in the Region Table 7 shows that the overall unweighted proportion of all facilities offering PAC is just above a third (38.%). Access to PAC is slightly better in Western than in Nyanza (40.0% v. 35.8%).There are 19 public service-delivery points (SDP) offering PAC, 15 private SDPs, and seven mission SDPs. 6 Facilities Offer any Offer uterine Offer uterine surveyed elements of evacuation evacuation with PAC with MVA sharp curettage % (n) % (n) % (n) Total Sample (41) 27.8 (30) 17.6 (19) Western Province (22) 25.5 (14) 25.5 (14) Nyanza Province (19) 30.2 (16) 9.4 (5) Public facilities (19) 26.6 (17) 6.3 (4) Mission facilities (7) 25.0 (4) 31.3 (5) Other private facilities (15) 31.0 (9) 34.5(10) Table 7: Administrators Report of Facility Provision of PAC by Province and Affiliation 6 More private facilities appear to offer PAC (51.7% v. 29.7%). However this is likely an artefact of the privatesector sample, which contains proportionally more hospitals than the public-sector sample (42.9% v. 22.8%). 21

24 Figure 2: Availability of Elements of PAC by Level (n=108) Figure 2 shows that at the hospital level in both provinces, PAC is widely available, currently offered in 25 of 34 facilities (73.5%). Slightly more than half (55.9%) of all hospitals offer MVA procedures. About half of the nursing homes surveyed also report some type of care, however the proportion falls to about a quarter when the question refers specifically to uterine evacuation with MVA. Although an imperfect comparison, due to differences in sampling strategy and coverage area,table 8 compares provincial PAC access information generated from the 1999 Kenya Service Provision Assessment (KSPA) data with that of the present study. Both surveys queried facility administrators in public, private and mission facilities. Both studies examined access in hospitals, maternity/nursing homes and health centres. 22

25 Kenya Service Ipas Baseline Provision Assessment Facility Assessment in 78 facilities of 108 facilities Sampling method Randomly selected 6 purposefully selected DHS clusters underserved covering 8 districts districts out of 20 out of 20 %(n) %(n) % of hospitals in sample 20.5 (16) 31.4 (34) Facilities offering any PAC services 46.2 (36) 38.0 (41) Facilities offering MVA 19.2 (15) 27.8 (30) Facilities offering sharp curettage 29.5 (23) 17.6 (19) Table 8: Comparison of PAC Access in Two Facility Surveys in Western & Nyanza The 1999 KSPA found 36 out of 78 facilities (46.2%) responded affirmatively when asked if they provided postabortion care or dealt with problems of abortion, however 9 (25%) of these purported PAC facilities offered neither MVA nor sharp curettage, the two most common uterine evacuation procedures. 7 So, while the proportion of self-identified PAC services among facilities surveyed appeared to have declined over the period, in fact access to MVA services may have doubled (15 to 30 facilities). 8 7 This highlights potential methodological problems with asking about postabortion care, a concept which appears to be not uniformly understood at the level of service-delivery points. 8 Although these comparisons require caution since some of the difference may be explained by the greater proportion of secondary- and tertiary-care facilities in the 2002 survey. Hospitals include public and private provincial, district and sub-district level hospitals. The definition of hospital is more problematic in the private sector. 23

26 Table 9: Availability of Specific Evacuation Techniques Among PAC Facilities by Affiliation 9 Offer uterine Offer uterine n evacuation with evacuation with MVA sharp curettage %(n) %(n) Total PAC facilities (30) 46.3 (19) Western Province (14) 63.6 (14) Nyanza Province (16) 26.3 (5) Public facilities (18) 15.8 (3) Mission facilities (4) 71.5 (5) Private facilities (8) 73.3(11) WESTERN NYANZA Table 9 shows uterine evacuation techniques among only those facilities reporting PAC services (41). Interestingly, less than half of mission facilities that reportedly provide PAC offer MVA procedures. 10 The World Health Organization s (WHO) Safe Abortion: Technical and Policy Guidance for Health Systems recommends MVA or medical abortion with MVA as back up for management of incomplete abortions up to 12 weeks. Only in the public sector is offering PAC virtually synonymous with provision of MVA (94.7%). Mission and private facilities are less likely to have MVA as the cornerstone of PAC. Moreover, Figure 2 and Table 9 show that the proportion of facilities offering sharp curettage is low. 11 WHO guidelines encourage the phasing out of sharp curettage for abortion care, so the finding that only 35.3% of hospitals perform sharp curettage may be viewed positively (WHO, 2003). However, additional inquiry is needed to confirm the low reported utilisation of this technique. 9 Proportions are not mutually exclusive. 10 Three mission facilities reported that they did not offer MVA; however a systematic random case review indicated documentation of eighteen MVA procedures. It is not clear if this indicates MVA procedures had recently been suspended or if disclosure of MVA availability in the mission-run facilities was controversial. Instrument sustainability problems in Kenya have led to interruption of services in the past (Kogi-Makau & Solo, 2000; Cobb et al., 2001). 11 This is probably an underestimate. 24

27 PAC Caseloads It is often observed that the public sector is the primary source of both modern contraception and health-care services in Kenya (Cobb et al., 2001). As a result, it is frequently inferred that the public sector is the major destination of most PAC patients as well. However, as shown in Figure 3 in Western and Nyanza, the public sector contributed slightly less than half (45%) of the incomplete abortion cases documented in the region. 12 Private 42% Mission 13% Public 45% Figure 3: Comparison of Aggregate Incomplete Abortion Caseloads by Affiliation Logbook reviews were conducted to generate caseload information over the study period. Data collectors in all but 2 facilities (39) were able to report the number of patients diagnosed with incomplete abortions over the three-month period of August 1-October 31, One of the striking findings of this study is the relatively high volume of PAC cases treated outside of the hospitals. As Table 10 reveals, although only a small number of primary-level facilities are equipped to offer PAC, among those that do, the volume is quite high. On average, more cases of incomplete abortion are handled in the maternity/nursing homes and health centres than at the hospital level. Although inferences based on such a small sample of primary-level facilities can be misleading, these findings confirm anecdotal reports that once PAC with MVA is made available at the primary level, much of the caseload can be managed without recourse to hospitals. 12 This may be an artefact of purposive sampling of larger private facilities. 25

28 Table 10: Comparison of Mean Caseloads for a 90 Day Period by Level Incomplete MVA Sharp n abortion procedures curettage case load procedures Hospitals Maternity/ Nursing Homes Health centres Total In this study, the reported caseloads for uncomplicated PAC were lower than expected. Among the 41 facilities offering PAC, 75% managed fewer than seven cases of incomplete abortion per month. Table 11 demonstrates that on average, the private sector manages twice as many incomplete abortion cases as the public sector (59.1 v. 23.6), but half as many MVA procedures (10.7 v. 20.1). Table 11 also highlights the low volume of sharp curettage procedures documented in facility logbooks. Over half of the facilities surveyed did not document the performance of a single sharp curettage procedure during the 90-day review period. 13 Table 11: Comparison of Mean Caseloads for a 90 Day Period by Affiliation Incomplete MVA Sharp n abortion procedures curettage case load procedures Public facilities Mission facilities Private facilities Total It is interesting to compare the number of patients diagnosed with incomplete abortion against the reported number of procedures performed, because it appears that a large proportion of abortion patients receive neither sharp curettage nor MVA uterine evacuation. WHO experts estimate that a quarter of patients with a diagnosis of incomplete abortion will not require an evacuation procedure of any kind (WHO, 1999). However, in this study up to two-thirds of women with incomplete abortions were managed without uterine evacuation. Several hypotheses may explain the absence of procedure information of PAC patients inside the facilities It is difficult to determine if these data reflect an authentically low provision of sharp curretage, deficiencies in record keeping, intentional under-counting or some combination of factors. The caseloads in the 41 facilities were not closely associated by facility size, level of complexity, or staffing levels, which further raises concern about the reliability of these values.

29 1. Poor record keeping (e.g. misclassification error) Patients may be receiving a tentative or default diagnosis of incomplete abortion but later clinical inquiry reveals other diagnoses that do not require uterine evacuation and the correction to the initial, presumptive diagnosis is never made. Logbooks are notoriously unreliable as primary sources for abortion information. 2. Over reliance on expectant management. Although WHO has determined that uterine evacuation is required in 75% of missed, incomplete, and inevitable abortion cases, in fact there are some clinicians that prefer to delay evacuation to see if uterine activity alone can expel the products of conception (WHO, 1994). 3. Alternative Management. There is some limited evidence from the National Magnitude of Unsafe Abortion Study that other informal techniques are used to expel the contents of the uterus, such as reports of digital removal and possibly the off-label use of misoprostol. 14 These reasons might partially explain the discrepancy between volume of incomplete abortion admissions and volume of evacuation procedures. When considered at the aggregate level, these discrepancies between patients booked and procedures performed are most apparent in the private sector, however, it is observed in all sectors and all levels of the health system. Low caseloads and low procedure volume cannot be equated with low demand for abortion services. Many factors influence a woman s decision to seek care for abortion services including the legal status and stigma of abortion, economic and opportunity costs, perceived efficacy and quality of services (Ronsmans et al., 2002). Anecdotal evidence from the recently conducted Magnitude of Unsafe Abortion Study suggests that some intentional under-reporting of the caseload is occurring among clinicians who work in both the public and private sectors (Gebreselassie et al., forthcoming). This selective record keeping may reflect the fact that some unknown proportion of the caseload at various facilities is in fact induced abortion. Moreover, there is anecdotal evidence to suggest that Western Kenya has a large number of induced abortion providers, safely operating at the community level in some areas.the availability of safe, elective services in these provinces may diminish the prevalence of abortion complications managed in the facilities surveyed. However, this is unlikely to fully account for the low volume of services identified. Poor record keeping seems the most likely explanation. 14 A recent survey of Ob/Gyns at the 2002 Kenya Obstetrics and Gynecology (KOG) meeting suggests some experimentation and increasing knowledge of medical abortion on the part of providers in Kenya. (Mwalali, 2002). 27

30 Use of MVA Technology Since 1987, Kenyan clinicians have demonstrated the benefits and feasibility of using MVA versus sharp curettage for uterine evacuation. Two landmark studies cited improved safety (Kizza and Rogo, 1990), decreased patient stay (76%) and reductions in treatment cost (66%) following the introduction of MVA provided on an ambulatory basis (Johnson et al., 1993). Today, the public sector has made MVA technology the preferred method for managing abortions up to 12 weeks. The majority of MVA procedures are documented in Kenya s public hospitals, at both the district and sub-district levels, with most of the MVA procedures occurring at the sub-district level. However, 75% of the facilities on our sample recorded fewer than four MVA procedures performed over a ninety-day period. MOH guidelines state that MVA should not be used after 12 weeks of pregnancy. In reviewing case records we found that clinicians generally adhere to these norms. Postabortion care of the second-trimester gravida is concentrated in a small number of facilities. Three hospitals in the region manage the vast majority (78%) of all second-trimester incomplete abortion cases: the Kakamega Provincial General hospital (42%), the Nyanza Provincial hospital (18%), and the Marie Stopes Maternity in Kisumu (18%). Cost of PAC Services A major burden on the Kenyan public-health system is the high cost of emergency treatment for complications from unsafe abortions, especially in the current climate of cost-recovery pressures and declining international donor support. The Kenyan health system has implemented some cost recovery measures, including user fees for PAC. The overwhelming majority of facilities surveyed (95.1%) charged women and their families for PAC with only two public facilities not charging for these services. In addition to user fees, 87.8% of facilities reported passing along the costs of supplies and medicines associated with PAC treatment. Moreover, 53.7% of facilities reported some degree of cost sharing for familyplanning methods as well. The mean cost to patients of sharp curettage was 3,976 K Sh (51.63 USD), whereas the mean cost of MVA was reported as 2,063 K Sh (26.79 USD). As expected, the median cost of either uterine evacuation procedure was significantly lower in the public sector than in the private sector (Table 12). 28

31 MVA (K Sh) Sharp Curettage (K Sh) Public 500 1,000 Mission 1,250 1,500 Private 2,000 4,500 Mean 2,063 3,976 The per capita annual income in Kenya was 350 USD in 2001 (World Bank, 2002), making the cost of PAC a significant burden upon the average Kenyan household. The role of price in driving the behaviour of women suffering from abortion complications is well established in the region (Rogo et al., 1999), and common sense would indicate that it is likely to represent a barrier among the most disadvantaged and at-risk families. Table 12: Comparison of Median Cost in Kenyan Shillings of Uterine Evacuation by Affiliation (n=41) The absence of uniform user fees and exemption criteria in the public-health system seems to be a barrier to women seeking maternal care in Kenya while also limiting researchers ability to correctly measure the affordability of that care (MOH of Kenya et al., 2000). Rogo and colleagues (1999) report that cost is the single largest decision factor in determining how to manage unwanted pregnancy. The potential for both cost-recovery and cost savings through the implementation of PAC with MVA is widely recognized. Prior Kenyan pilot studies have shown that following the shift to an ambulatory care model of PAC services, costs fall as much as 66% and patient stays decrease by 76% (Johnson et al., 1993). However, the non-monetary investments required for the reorganization, implementation and institutionalisation of PAC services are often under-appreciated (Benson and Huapaya, 2002). Facility Infrastructure for PAC Service Availability The capacity to provide PAC using MVA depends on the presence of certain minimum standards and infrastructure.the typical PAC facility in this assessment has one operating theatre and 8 beds or less. As expected, facilities without PAC tend to be smaller. Access to running water and toilet facilities was nearly universal at all facilities, and will not present barriers to the introduction of PAC even at the health-centre level. 29

32 Table 13: Percentage of Facilities with Stocks of Essential Drugs to Treat Complications of Abortion by Affiliation (n=108) Table 14: Percentage of Facilities with Stocks of Essential Drugs to Treat Complications of Abortion by Level (n=108) Essential Drugs and Infection Prevention According to our survey, the drugs used to fight infections and injuries from unsafe abortion are widely available in Western and Nyanza provinces.table 13 shows that public, private and mission facilities stock essential drugs for treatment of abortion complications. n Oral Parenteral Adrenaline Aminophylin Hydrocortizone antibiotics antibiotics Public Mission Private Total Table 14 shows that health centres and nursing homes are as well stocked, generally, with life-saving essential medicines for emergency treatment as hospitals. n Oral Parenteral Adrenaline Aminophylin Hydrocortizone antibiotics antibiotics Hospital Nursing Home Health Centre Pain management is an important facet of PAC that is often under-appreciated in Kenya (Solo et al., 1998). Pain management often varies by patient and a range of methods is needed. Table 15 indicates that public, private and mission facilities all stock a wide variety of pain management medications. Table 15: Percentage of Facilities with Stocks of Pain Management Medications by Affiliation (n=108) Analgesics Atropine Diazepam Local General n Anaesthesia Anaesthesia Public Mission Private Total

33 Various pain management drugs are also found universally at the health-centre level, including analgesics such as paracetemol (96.5%), diazepam (100%) and local anaesthesia (100%) such as lidocaine. Analgesics Atropine Diazepam Local General n Anaesthesia Anaesthesia Hospital Nursing Home Health Centre Table 16: Percentage of Facilities with Stocks of Pain Management Medications by Level (n=108) At the time of stock review, general anaesthesia was only available in 27.5% (30) of the facilities in this sample, whereas local anaesthesia is universally available (Table 16). Despite the availability of local anaesthesia and its recommended usage, record review suggests that it is very rarely used in Western and Nyanza for pain management during uterine evacuation (see Table 45). Infection prevention is an important part of quality care and an important part of MVA training. Most facilities in this survey showed some capacity for infection prevention procedures, having either a decontamination bucket (60.2%) and/or an autoclave (66.7%). Table 17 reveals that the private sector is better equipped to process instruments than the public sector or the mission facilities, at this point in time. Decontamination Autoclave Boiler Other n bucket sterilizing equipment Public Mission Private Total Table 17: Percentage of Facilities with Instrument Processing and Infection Prevention Equipment by Affiliation (n=108) As expected, the higher-level facilities are better prepared to prevent infection at this time. Table 18 indicates that only 45.6% of health centres have a functional decontamination bucket, and/or autoclave (50.9%). 31

34 Table 18: Percentage of Facilities with Instrument Processing and Infection Prevention Equipment by Level (n=108) Table 19: Percentage of Facilities with Infection Prevention Supplies by Affiliation (n=108) Table 20: Percentage of Facilities with Infection Prevention Supplies by Level (n=108) n Decontamination Autoclave Boiler Other bucket sterilizing equipment Hospital Nursing home Health centre The private sector and mission facilities appear better stocked with agents to process instruments.the public sector suffers from shortages of basic disinfection supplies, including sterilizing agents (39.1%) and bleach (51.6%). Further exploration of the supply logistics and bottlenecks is needed before PAC can be put into practice at these sites. n Sterile gloves Antiseptics Bleach Sterilizing/HLD agents Public Mission Private Total As expected, hospitals are generally well equipped to process MVA.Table 20 reveals that supplies of infection prevention consumables, in particular sterilizing agents, are not consistently available at the health-centre level. One-third of all health centres lack sterile gloves (32.4%), a bare necessity for both diagnosis and treatment of abortion complications. n Sterile gloves Antiseptics Bleach Sterilizing/HLD agents Hospital Nursing home Health centre In this baseline, 37% of respondents reported using Steranios/Cidex for processing of MVA cannulae. Another third (37%) of respondents reported using Jik (a 3.5% bleach solution) as a disinfectant, which is a suitable treatment when Steranios or Cidex are not available. 32

35 Blood Oral Stethoscope Eye n pressure gauge thermometer protection Public Mission Private Total Table 21: Percentage of Facilities with General-Purpose Equipment by Affiliation (n=108) Table 21 indicates that facilities in this study are lacking blood pressure cuffs, an elementary tool of primary care. On average, only a third (35.2%) had a blood pressure gauge.the public-sector health centres lack equipment to gather basic vital signs necessary for fulfilling their treatment and referral functions (Table 22). Blood Oral Stethoscope Eye n pressure gauge thermometer protection Hospital Nursing home Health centre Table 22: Percentage of Facilities with General-Purpose Equipment by Level (n=108) Table 23 shows that the diagnostic tools to detect incomplete abortions are largely available, although public-sector facilities are more likely to lack the full complement of specula. Graves Graves Graves Tenaculum Needle n speculum speculum speculum extenders (small) (medium) (large) Public Mission Private Total Table 23: Percentage of Facilities with Selected Functional Gynaecology Instruments by Affiliation (n=108) The relative scarcity of small specula at nursing homes (35.3%) and health centres (17.5%) may limit a facility s capacity to meet the reproductive-health needs of adolescents and partially infibulated women. As indicated in Table 24, few health centres have tenacula (15.8%), a necessary tool for uterine evacuation. 33

36 Table 24: Percentage of Facilities with Selected Functional Gynaecology Instruments by Level (n=108) Graves Graves Graves Tenaculum Needle n speculum speculum speculum extenders (small) (medium) (large) Hospital Nursing home Health centre Intravenous fluid and electrolyte replacement are essential for interim management of haemorrhage, as well as a critical vehicle for administration of parenteral antibiotics for the treatment of infection and sepsis. In Table 25 it appears that over two-thirds of all facilities are stocked with intravenous equipment and supplies. Table 25: Percentage of Facilities with Functional Intravenous (IV) equipment and Supplies by Affiliation (n=108) Blood Blood Disposable IV IV IV IV n products/ giving syringes/ Sets cannulae fluids stand expander sets needles Public Mission Private Total Access to intravenous fluids is paramount for both the treatment of unsafe abortion, as well as interim stabilization for transport. Table 26 highlights the fact that hospitals are generally equipped to offer life-saving intravenous fluids, however given their role as referral points it is surprising that only two-thirds stock blood products and/or expanders. Transfusion capacity is a key indicator of the ability to respond to a host of maternal morbidities and a necessary component of comprehensive obstetric emergency care. Health centres stock of these supplies is understandably limited, with only 14.0% offering blood transfusion capacity. 34

37 Blood Blood Disposable IV IV IV IV n products/ giving syringes/ Sets cannulae fluids stand expander sets needles Hospital Nursing home Health centres Table 26: Percentage of Facilities with Functional Intravenous (IV) equipment and Supplies by Level (n=108) Furniture is widely available in most facilities and very few health centres lack essential furnishings to provide PAC. As described in Table 27, some public sector sites (39.1%) lack exam tables, a necessary piece of furniture required for PAC implementation. Exam Instrument Stool/ Stepping Adjustable n table with tables/ revolving stool floor lamp stirrups trolley/tray stool Public Mission Private Total Table 28 shows that while health centres have instrument trolleys (94.7%), a fair number do not have an exam table with stirrups (40.4%) that would be needed to inaugurate PAC at that level. Table 27: Percentage of Facilities with Essential Furniture in Functional Condition by Affiliation (n=108) Exam Instrument Stool/ Stepping Adjustable n table with tables/ revolving stool floor lamp stirrups trolley/tray stool Hospital Nursing home Health centre Within the facilities, two different respondents were queried about instrument availability clinicians and stock managers.the two informants provided similar Table 28: Percentage of Facilities with Essential Furniture in Functional Condition by Level (n=108) 35

38 reports. Table 29 uses two data collection methods to compare the availability of MVA. A little over a third of the facilities had MVA technology on the premises (35.2%). Among self-identified PAC providers, possession of MVA equipment increases to roughly three-quarters (75.6%). That corresponds roughly to the number who report offering MVA procedures (73.2%). 15 Access to cannula is not as much of a limiting factor as syringe access. Twice as many facilities reported having MVA cannulae (68.5%) as having syringes. Table 29: Facilities with MVA Technology by Data Collection Method (n=108) Functional MVA syringes available? Stock Syringes n supervisor directly recall observed Public facilities Mission facilities Other private facilities Hospitals Nursing homes Health centres PAC facilities only Mean Previous research has shown that access to instruments is restricted in some facilities to preclude theft, a practice that may have the inadvertent effect of compromising awareness and use of the technology (Gebreselassie and Fetters, 2002; Cobb et al., 2001). Streamlining instrument procurement is the on-going challenge to increasing MVA use in Kenya (Cobb et al., 2001). Among facilities in this survey, 66.7% (22) of sites with MVA obtained their instruments from NGO donations. Principal among NGOs donating were Kisumu Medical and Educational Trust (KMET) (38.1%), Population Council (19.0%), Ipas (14.3%), AMKENI (14.3%) CHAK (9.5%), and Marie Stopes (4.8%). Only 21.2% of MVA donations were in the context of training in MVA usage. Only 3.7% of facilities obtained syringes through direct purchase from a distributor or manufacturer. Although there has been a network of distributors in Kenya for some time, sustained access to MVA syringes and cannulae at the facility level has been an on-going problem. For a number of years, it was the 36

39 policy of the MOH not to procure the MVA instruments directly from Ipas, the principal supplier, on the grounds that the product was too expensive (Cobb, 2001). Efforts to identify a lower-cost aspirator were not successful. Supplies of Ipas MVA syringes were only obtained through donor subsidy plans, local distributors and complex bilateral and multilateral aid organization disbursement. However, in late 2002, Ipas made the first direct MVA tender with the MOH. It is hoped that the three-pronged strategy of direct Ministry procurement, donation, and local distribution will represent a more sustainable, long-term solution to address the aspiration technology needs of the Kenyan public and private sectors. Human Resources and Training in PAC In addition to the physical capacity to provide services, there are organizational priorities and management decisions about staffing that determine a site s capacity to render PAC services when they are needed.the ability to provide all five essential elements of PAC typically depends upon a multidisciplinary group of health professionals within the facility. Staffing of Service Delivery Points The 1999 Kenya Service Provision Assessment Survey (KSPA) queried health workers on what hindered their job performance. Staff shortages were cited by half of those surveyed. This baseline assessment of particular facilities in Western and Nyanza provinces echoes that concern. Staff shortages limit both the current capacity to offer PAC, as well as the potential to implement it in new facilities. In 8 out of 41 current PAC sites (19.5%) the ability to render care was predicated on the presence of a single individual, often someone with only on-the-job training. This raises concern about the availability of services 365 days a year, and reinforces the need for additional training to assure that existing services are resilient to fluctuation in personnel. Even in nominally operational PAC facilities, questions regarding the availability of PAC during the night and weekend shifts elicited some contradictory responses. Universally, administrators (100%) reported that PAC services were available twenty four hours a day, seven days per week. However, when clinicians were queried about who specifically provides uterine evacuation procedures during night and weekend shifts, the answers revealed more restrictive access in one out of five sites. Seven facilities (17%) can provide PAC only if they are successful in summoning off-duty clinicians.two others (4.9%) in fact refer all patients who 37

40 arrived at night to other facilities. The effectiveness of on-call versus in-house staff is predicated on the reliability of communication and transport infrastructure, as well as the safety of night-time travel. In urban centres of Western and Nyanza on-call staffing may be effective, however in many parts of the predominantly rural provinces, on-call staffing may incur delays in life-saving treatment. Staff shortages appear to be a constraint upon future expansion of comprehensive abortion care at the health-centre level. Surprisingly, only 23.5% of hospitals have an obstetrician-gynaecologist, on staff and almost half have no anaesthesia capacity, so acute complications cannot be managed routinely at that level. In Western and Nyanza provinces the scarcity of medical doctors in the hospitals is pronounced. Table 30: Percentage of Physician Staffing in All Facilities by Cadre Hospitals Nursing Health (n=34) Homes Centres (n=17) (n=57) 1 or more Ob/Gyns or more anaesthesiologists or anaesthetists 1 or more medical officers Table 31: Comparison of Physician Prevalence in PAC Versus Non- PAC Facilities PAC Facilities Facilities without PAC (n=41) (n=67) Provider Type Percentage with Percentage with 1 or more 1 or more Physicians Obstetricians Gynaecologists Anesthesiologist/Anesthetist Other Specialists Medical Officer These data from Tables 31 and 33 suggest that due to shortages of physicians and midwives, extending PAC to new facilities will necessarily involve the recruitment of clinical officers and nurses as the main audience for MVA training. Fortunately, following successful pilot testing, the MOH has gradually authorized the provision 38

41 of postabortion uterine evacuation services by a wider variety of health professionals, including clinical officers and several cadres of professional nurses with midwifery training. 15 This latter category includes: Kenya Registered Nurses Kenya Registered Nurse Midwives, Kenya Enrolled Community Health Nurses, Kenya Enrolled Community Nurses, Kenya Registered Community Health Nurses, All of the nursing professionals listed above undergo pre-service midwifery training that provides an adequate basis for subsequent uterine evacuation training (Kogi-Makau and Solo, 2000). As Table 32 shows, nurses and clinical officers are widely available at all levels of the health system. Hospitals Nursing Health (n=34) Homes Centres (n=17) (n=57) Clinical Officer Kenya Registered Nurse-Midwife (KRN/M) Kenya Registered Nurse (KRN) Kenya Enrolled Community Health Nurse (KECHN) Kenya Registered Community Health Nurse (KRCHN) Kenya Enrolled Community Nurse (KECN) Table 32: Percentage of Facilities by Level with One or More Cadres of Midlevel Staff As Figure 4 confirms, all of the sites in this study have at least one eligible provider and in the sites where new services will be implemented, there are typically between 3-5 eligible trainees. A special strategy may be needed to address the 15 The availability of permanent methods, such as tubal ligation and vasectomy, were not explored in this study. 39

42 sustainability concerns at the 17 (15.7%) sites where there are two providers or less. The quality and sustainability of PAC often depend on the presence of peerprovider networks, supervision, and an institution-wide appreciation of the value of services (Benson and Huapaya, 2002). Figure 4: Comparison of Staffing by Cadres in PAC Versus Non-PAC Facilities Table 33 shows that in order to implement PAC services where they do not exist, the recruitment of clinical officers and Kenya Enrolled Community Health Nurses (KECHN) will be paramount, as they represent the largest cadres of eligible professionals in non-pac facilities. Other nurses and midwives will also be important, however they are less prevalent at the service-delivery points. The presence of cadres such as KRN/M (14.7 %) KRN (11.8%), KRCHN (22.1%), or KECN (23.5%) in the Non-PAC facilities is limited. 40