The results of this study were shared with stakeholders through a series of four dissemination meetings between January to September 2018. The purpose was to identify barriers and facilitators and mechanisms for improving contraception and PAC services were discussed. The agreed course of action was then implemented with stakeholders’ support. Table 1 describes the study process over timeline.
TABLE 1 HERE
A total of 136 individuals participated in the study: 85 (62.5%) women and 51 (37.5%) men; mean age was 29.3 years; 77 (56.6%) participants had completed secondary school (Table 2). Approximately 5% refused to participate in the study mostly citing personal reasons and lack of time.
The result sections are organized to highlight issues in contraception, ZIKV infection and PAC services, respectively.
TABLE 2 HERE
Knowledge on contraceptive methods: Most participants knew at least one contraceptive method. The most frequently mentioned were pills, injections and implants, while less frequently mentioned methods were intrauterine devices (IUD), male condoms and surgical sterilisation. Both female and male participants knew about female condoms but lacked detailed information about it. Both men and women said that although they knew they could choose different contraceptive methods, they would like to receive more detailed information on each individual method, specifically regarding their adverse effects and efficacy.
“They don’t provide advice regarding family planning and they only ask “What kind of family planning do you want?” without informing the patient about the side effects of the different methods, for example the risks that an IUD can bring in the future, or the risks of the injection, so I end up choosing the method that a friend recommended”. (Focus Group, women, Hospital).
Attitude towards contraception: Participants generally had a positive attitude towards the use of contraceptive methods. Women and their partners said they did not feel stigmatized for seeking information on methods at the health facilities. Few men said they did not allow their partners to use contraceptive methods, while others thought contraceptive use should be a shared decision. Despite the knowledge about contraceptive methods and the positive attitude, many participants specified that their children had not been planned. In fact, many women said that they had sought contraceptive methods only after giving birth.
Concerns about methods: Many participants shared doubts about the effectiveness and the adverse effects associated with contraceptive methods and had concerns on the lack of comfort when using them. Most participants acknowledged that the effectiveness of each contraception method varied with each person. In fact, women thought that although physicians had information on the methods, they may not know how individual women’s bodies would react to each method. Many participants provided anecdotes involving the experience of friends or family that supported their perception that any method, even surgical sterilisation, could fail.
“This guy had sex with a lady, and she got pregnant, and he said it was not his baby…. And then there was a fight at home. When he came to the hospital he got examined and he really was fertile even though he had been operated! Could you just imagine if he had killed that woman!” (Focus Group, Women, Clinic).
Women most commonly accepted and used hormonal contraception; indeed, many preferred the three-month injection because it was freely distributed at the public hospital and was easily accessed. Participants’ main concerns regarding hormonal methods were their efficacy and their association with cancer, infertility, weight gain and skin blotches.
“I am scared of implanon [implant], I´m honest. No doctor will tell you the truth, they tell you the implanon will cover this or that, but they won´t tell you that in the future it will give you cancer”. (Focus Group, Women, Clinic).
Pills though had a burdensome daily regimen, were considered a very effective method. Participants had information on morning-after pills but explained that the use of this method was frequently associated with rape. For men, the most popular method were male condoms; however, they would use it for STI rather than for contraception. Of note, only a few participants included Zika in the group of diseases that could be prevented through condom. Some male participants were aware of surgical sterilisation (vasectomy), although only very few men were considering having it.
Barriers in access - distance and hospital hours: Participants observed that opening hours at health centres were limited and that the distance between their homes and the health facilities was a significant access barrier. Therefore, participants often arrived at the hospital at 4 am to secure an appointment. Most of the participants said that the admission process was disorganized and difficult and that waiting times were very long and thought the probable cause of delays was insufficient numbers of staff and lack of administrative organization.
“Look, I came here on Sunday, at 9 am and they told me I had to come back at 1pm. I came back at 1pm and they told me they were not open because they were going to disinfect the place. So, I came back on Monday and told me to stay on a line of people, I tried to explain to the girl, so they told me to return in the afternoon”. (Interview, Woman, Clinic).
Regarding infrastructure, some participants complained that the toilets were not clean; however at the last round of survey, a few participants acknowledged there had been some improvements in cleanliness and infrastructure.
Quality of services: Participants said that counselling services on reproductive health, especially on contraception were inconsistent and insufficient. Those who wanted to use contraception, received information provided at compulsory meetings only. Several participants suggested that health professionals should proactively approach people and give them more information on reproductive health and that counselling service should be extended to all even during the afternoons and evenings.
“The service here (public health centre) is not the same as in a private clinic where you have to pay because here there are so many people. The doctors have to see so many people that they cannot have a special relationship with you” (Focus Group, Women, Clinic).
Privacy and confidentiality: Some women felt uncomfortable during the consultations due to lack of privacy. Participants preferred women service providers.
“I don’t know why, but with women we have more confidence, though some men are more sensitive sometimes, but for intimacy issues it is better to have a woman [as health personnel]”. (Focus Group, Women, Hospital).
Often, single women sought counselling service and information in clinics outside their communities to avoid the embarrassment of being recognised by neighbours or healthcare staff. Moreover, it was reported that, sometimes, confidentiality was ignored by health staff, and this contributed to users’ mistrust in the services.
“You know what I´d change? I´d make this office private for women who come here for the (DMPA) shot, because you have to pull down your trousers, and you really feel embarrassed, sometimes in presence of three, four, five other people there” (Focus Group, Women, Clinic).
Access to methods: Participants stated that they could receive some contraception methods free of charge, including three-month injection, condoms and IUD. However, participants perceived that the condoms freely distributed at health facilities were small and of bad quality; therefore, when needed, they preferred buying at the pharmacies. Those condoms were considered to be inexpensive, of better quality and accessible in nearby vicinity. No improvement in services were perceived by the participants throughout the interview rounds.
ZIKA VIRUS INFECTION
Transmission of zika: Participants were aware that Zika was mainly transmitted by mosquitoes. Participants mentioned that pregnant women could be infected if they had sexual intercourse with an infected person and that this could be avoided using condoms.
“I know that (Zika) is transmitted by the mosquito, that is the main thing, and that we have to pay attention if we have the basins, if we have plants and barrels, we have to keep them clean to avoid larvae and mosquitos at our houses” (Focus Group, Women, Hospital).
However, from rounds one to three of survey, the number of participants who also knew of the possible sexual transmission of Zika, decreased.
Risks involved in zika: Participants mentioned that Zika infection was associated with serious risks for pregnant women. Most mentioned that the baby could get sick, die in the womb, have problems in the head and brain; suffer from microcephaly. Fewer mentioned the Guillain-Barré syndrome and malformations. There was confusion among participants about the difference among Dengue, Chikungunya and Zika infections. For them, the three diseases had the same symptoms and consequences in men or in non-pregnant women. This perception didn’t change in the different rounds of interviews.
“Well, I´ve heard that it affects people, pregnant women, and the baby. When someone is infected, they can infect the baby and cause complications” (Focus Group, Women, Hospital).
“We must be careful, if we are pregnant, we should be especially careful of not getting a bite, because the baby could be affected“. (Focus Group, Women, Hospital).
Sources of information on zika: Most frequently mentioned sources of information were television and radio, followed by Facebook and informative posters at health facilities. During round one survey, participants recalled having received information through mass or social media on how to avoid or control mosquitos at home and recalled having seen images of babies with microcephaly.
“What I know is how to prevent the disease, but not how to take care of oneself once you get the disease; most of all I know about prevention, that includes a clean household and getting rid of all possible mosquito breeding places and that is what they mainly talk about in the news” (Focus Group, Women, Hospital).
Health professionals were the most reliable source of information. However, at the last round of survey, at the end of epidemic, fewer participants received information or noticed any brochures or posters at the health facilities.
“Information on Zika is only available when there is an outbreak, they give information to prevent the disease. Why is information available only during outbreaks?” (Focus Group, Men, Hospital).
Prevention of Zika: Participants mentioned that they knew of some preventive measures mostly related to the vector transmission; such as covering the water tank (called pila) and cleaning it; however, the information on the frequency of cleaning was not clearly communicated.
“We should wash well the sink with chlorine, if you see a tire there with water you must empty it, if you have a leak, or containers full of water they have to be emptied, because that is where the mosquito comes from, wash all the ditches, everything has to be cleaned as much as possible “ (Focus Group, Women, Hospital).
They knew to use repellents, mosquito nets and coils, and cut tall grass and bushes. Less frequent practiced methods were covering buckets, cleaning gutters, or using a fan to repel mosquitos. Aside from the measures they knew of, participants explained they cleaned their house, and used larvicide and bleach in water tanks. However, many participants were against burning mosquito coils (Plagatox, as its commercial name) because the smoke caused cough. Of note, by the third round of interviews, participants stressed that actions performed by public and technical teams in the prevention of Zika in neighbourhoods had ceased.
Healthcare seeking behaviour for Zika infection. Upon suspicion of Zika, few participants sought care at a health centre and were referred to a hospital to confirm the diagnosis. However, not everyone attended a health centre; some were diagnosed by a relative who knew of the disease and its symptoms. Moreover, these patients self-medicated with acetaminophen and liquids, based on their experience they knew how physicians treated other cases of Zika infection.
POST-ABORTION CARE (PAC)
The process for women receiving PAC services at the Gynaecology and Obstetrics Emergency Room at the hospital is described in Figure 1.
Women seeks emergency obstetric care because either they are referred by a health centre or hospital to manage symptoms such as bleeding or pain; or because they are following up treatment with the drug misoprostol (A). Someone (partner, relative, etc.) may or may not accompany them to hospital (B). Those accompanying the women are not allowed inside the premises of the hospital. At the entrance of emergency gate, women are searched by security personnel and then escorted to a waiting area; those who are not ambulatory are assisted by hospital assistants in wheelchairs. In the waiting area, medical students interview the patients and refer them to specific services. Women needing PAC services are admitted to the Gynaecology and Obstetrics Emergency Room (C). Women in emergency are attended round the clock and those with suspected pregnancy are offered pregnancy test (rapid test).
Physicians register patients’ data and this registry is completed and collected daily by the statistics department. Misoprostol is prescribed and ultrasound is performed on all women. Patients under observation receive family planning counselling in the same room.
FIGURE 1 HERE
Geographic and economic challenges in accessing PAC services: Women when referred, are warned that reaching hospital could take them up to two hours, or even more if transportation was unavailable. Participants complained that no other public hospitals offered PAC and highlighted the need for these services to be closer to their homes.
“I decided to come today because I was bleeding so much, I fainted, had cold sweats, nausea and my body was shaking” (Interview, Woman with MVA procedure, Hospital).
Women had to cover the transportation cost to the only hospital that offered PAC services in the city, and had to pay 200 Lempiras (approx. US$8) per treatment. However, it could reduce to 50 Lempiras (approx. US$2) if social services office certified that the patient could not afford the full fee. Moreover, the hospital also required the patients to bring a gallon of water to clean the medical equipment.
Some patients had to pay for their medication and most women paid for a rapid pregnancy test. It was mentioned that misoprostol, anti-inflammatory agents and analgesics were not freely available; instead, patients had to buy them out-of-pocket. Many times, these payments for specific treatments were out of reach of patients.
“They asked me to buy a pregnancy test. Afterwards when they were about to perform the MVA they told me that I had to pay 200 Lempiras and purchase a container of water”. (Interview, Woman, Hospital).
By the final round of this survey, following discussion of research team with health authorities, this requirement and the fee was eliminated. The hospital administration purchased a water filter system for emergency room and medical staff with research study´s funds.
Absence of waiting space: Participants complained that male partners and relatives were not allowed into the hospital and had to wait long hours without any protection from the weather; slept on the floor at night and received no updates on the health of their partners from physicians or nurses.
“The cleaners just started to throw water on the floor, they didn’t mind if I had my clothes there or if I was sitting there. I was sitting there, after two nights without any sleep, I fell asleep on my bags on the floor and when I woke up because someone told me to, they were throwing water at me” (Interview, Man, Hospital).
They remained unaccompanied in the waiting area and during the procedure.
“Through emergency, I got her [wife] in and the guard treated me badly because I came with her and he told me that I couldn’t go in and I told him that it was an emergency because she was my wife and she was really sick and had problems. (Focus Group, Men, Hospital).
Insufficient infrastructure for services: A very common complaint during the first round was the lack of privacy for the women who sought assistance or during a procedure, including the lack of sufficient beds or rooms. Most participants complained that the admission process was disorganised, difficult and time-consuming, the public toilets were unclean, and medications were often lacking.
The reproductive health counselling was only given after MVA procedures were performed, with no privacy and in the presence of other patients. Over time, participants acknowledged some improvements specially ward cleanliness.
Mistreatment and abuse: Many participants agreed they had been mistreated by physicians and nurses when seeking PAC or emergency care. Some of the women felt that they were laughed at, reprimanded and ignored by both physicians and nurses.
“Today, I was undergoing the MVA, the doctor was doing the procedure with people standing by the door, there was a student asking one thing and another and doctor´s phone kept ringing”. (Interview, Woman, Hospital).
The most common complaint was the staff’s lack of empathy and indifference to their health situation.
“My mom asked for information because when I was in the ward and there were many girls who had had an abortion and they told me “you have to rest, you can´t crouch, you can´t travel”. So, I told mom to get information. The first time I had an abortion, they didn’t explain anything to me, they just told me “go away and take care!”, just that. So, my mom asked a nurse and she just said I had to rest, just that" (Focus Group, Women, Hospital).
Accompanying male partners and female patients described instances of mistreatment by the security staff when being admitted to the hospital. The male partners mentioned that they did not receive information about the patients’ health and procedures during in-hospital stay, the remarked they feel mistreated and that produced distress and fear.
“My partner was being accompanied by her sister. I could not get in touch with my partner, I could not even call her on the cell phone. Then, I could talk to her sister, she called me, she was crying and told me that my baby´s heart was not beating and the doctors had performed an ultrasound and had seen my baby was dead and that they going to do another ultrasound” (Interview, Man, Hospital)
Quality of services: Some women complained of having to wait for long hours in pain, only to receive what they perceived as unsatisfactory care. Some women who were prescribed misoprostol felt that they had been discharged without adequate information as they felt staff did not sufficiently explain the procedures to them. Some patients reported that physicians did not treat and even ignored the symptoms they complained about, in particular, pain. After unsuccessful treatment in their own home, some participants had to return to hospital for treatment.
“It is a horrible sensation, because one feels as if they are pulling the uterus and the doctors only tell us to cooperate but that is, it is impossible to stay relaxed, when one is going through something so painful.” (Interview, Woman, Hospital).