A total of 20 providers were interviewed. Majority were males (12/20). One was a Clinical officer, two were Midwives, seven medical doctors and ten were registered nurses. Years in Practice varied from 2 months to 10 years.
Two main categories emerged from the data analysis: (1) health system-related factors and (2) individual moral factors. The categories on barriers and facilitators in the provision of CAC are presented in Table 1.
Table 1
Summary of barriers and facilitators of CAC service provision
Category
|
Barriers
|
Facilitators
|
Health system Factors
|
Shortage of staff
|
Mentorship
|
|
Provision of service optional
|
Trainings
|
|
Lack of privacy in the rooms
|
Partner support - IPAS
|
|
Inadequate Space
|
Accessible services
|
|
Constant Shortages of supplies and medication
|
Legal framework
Task shifting
|
|
Lack of equipment
|
No impact from covid
|
|
|
Task shifting
|
|
Medical Supplies and equipment
|
|
|
Constant Shortages of supplies and medication
|
|
|
Lack of equipment
|
|
|
Service delivery
|
|
|
Preference of being anonymous
|
|
Individual moral factors
|
Moral conflicts - Religious beliefs
|
|
|
Stigma
Fear of being Labelled
Fear of recognition
|
|
Barriers to provision of CAC
1. Health system related factors
Discussions around the number of CAC providers in the facilities revealed that health care providers of CAC were inadequate, and not many were trained in CAC service provision. This poor number of trained providers was cited as a contributor to staff shortages. Respondents in some facilities narrated how overwhelming it was for them to provide the service as they had other competing duties besides provision of CAC services.
“…Uhh we are few, and looking at the number of patients we receive I can say it’s overwhelming, because in our department we are just the three of us. And most times we sacrifice our own off days just to cover.” (Registered nurse, 2 years in service)
“…There are few people that offer the service. So, it is a challenge. That's why others have to wait for days before they could meet you. Okay, and others [HCPs] they'll call you as I mentioned, the people in our emergency gynae, they will call the lines of the service for those ones that provide the service.” (Doctor, 6 years in service)
Although there are a number of health care workers who are willing to offer CAC services, it was reported that, lack of training limited service provision. Some partners that support training were mentioned as being Ipas and Mari-stopes. These are the same partners that offer refresher courses to CAC providers.
1.2. Optional CAC service provision
HCPs stated that they were readily available to provide CAC services. However, service provision for CAC was reported to be optional as some HCPs who found the service immoral had an option to provide the service or not which overwhelmed the few who were unconditionally willing to provide the service.
“So here, it's difficult to know the actual number because there are some that are providers but don't want to be… they don't want to come out as providers because of the stigma that comes with us providers of termination of pregnancy services.” (Registered Nurse, 8 years in service)
1.3. Infrastructure
Spaces for service provision were reported to be a challenge. Some respondents stated that the spaces were limited hence used for many other services. Some respondents who were concerned with space for counselling and privacy had this to say,
“…Okay, [uh] the challenges to say, [ok, yeah]what happens is [uh] we don’t have a proper room for counselling, you know it’s a comprehensive abortion care, that means, it includes counselling, we need to take time to explain to the patient until she’s ready to undergo the procedure. So we don’t have a room for counselling and that’s the main challenge because most of the time we have to do it in the open place and the people are able to hear. And some can start, you know [uh] saying all sorts of things which is not correct.” (Midwife, 8 years in service)
“…It’s the issue of privacy. If you've seen our arrangement in our emergency gynae, patients sit back-to-back, one this side, one this side. Now imagine the other side, you've got someone who has infertility, for example, they are looking for a child and then another one on the other side is looking to terminate a pregnancy. So, it's important to have separate rooms, for confidential consulations and privacy. A room dedicated only to such services [CAC], would have been good.” (Medical doctor, 4years in service)
1.4. Medical supplies and equipment
Frequent shortages of medical supplies were reported as another significant challenge for the provision of CAC services. For instance, some respondents reported that some sites would receive surgical abortion kits and medications through hospital funding, including from partnering organizations, but the frequent pattern was no longer there due to reduced funding.
“We haven't had the supply of combi pack. Okay, the medication that we use for termination of pregnancy that is as a hospital. Okay, I think last time we received those supplies from IPAS. It's been, I think it was last year. Okay. And then the MVA kits, at least we got some, I think about two weeks ago about 10 of them that are new now because even them they're not working properly. So at least we got a new stock, but we have been limping in terms of supplies.” (Medical doctor, 9 years in service)
It was also reported that some of the kits available for surgical procedures were old, and one has to manoeuvre around to make it work. Providers further described situations where they have to prescribe medication for the patients to purchase or return on another day, hoping that the medicine would have been supplied to the facility.
“So many times we actually write prescriptions for like combi pack so they can go and buy before you offer the service and it's expensive.” (Registered Nurse, 3 years in service)
1.5. Lack of incentives
On addressing the question of whether providing the service comes with an incentive, the general answer was that, this was not the case as the service was regarded as part of the usual work. This was noted as a barrier to service provision as some health workers would be motivated and others more willing to provide the service if an incentive outside the salary was provided.
“There is nothing, and that's another hindrance because sometimes you have to come from home sometimes just to feel for someone, people negotiate. No, this one has been coming here for three, four or five days. Okay, so you end up coming here [health facility], there are no incentives my dear.” (Medical doctor, 4years in service)
Provision of CAC was reported as taxing and that most times providers had to go out of their way to see a patient.
“It would be good if there is an incentive for the service providers cause maybe that’s why people are not willing cause usually when I admit a patient as long as it’s written TOP, when that patient expels even if I have knocked off I will be called and I get to use my own transport. so an incentive would be better.” ( Medical doctor, 4years in service)
2. Individual moral factors
2.1. Religious affiliation and personal beliefs
The belief that TOP is immoral was reported as one of the reasons most HCPs do not provide CAC services. Being a Christian and wanting to maintain good standing in their faith was cited as reason to only attend to patients who reported to the facility with spontaneous abortions.
“Okay, so it's mixed feelings. Others attach religious affiliation to it. others, It's just on an individual basis.” (Medical doctor, 4 years in service)
“…there’s some who don’t actually believe in the whole thing due to conserving their Christianity values.” (Midwife, 8 years in service)
“some staff would be like no, in as much as I was trained I can’t do a termination because of my personal beliefs or religion.” (Registered nurse, 3 years in service)
2.2. Stigma and anonymity
CAC providers preferred to remain anonymous due to the stigma surrounding service provision. Abortion is broadly considered evil by society, and those associated with it are promoters of immorality. This attitude was from fellow healthcare providers. The respondents reported that this attitude led to some providers preferring to be incognito when providing the service. One respondent explained:
“There’s stigma amongst health personnel so that they negate those that provide the service. They will look at them as you know, the evil ones. So others don't want that stigma and they prefer to remain incognito. They don't want to be known for providing the service except for a few that will come out.” (Medical doctor, 6 years in service)
2.3. Fear of being Labelled as murderer
The other individual factor cited was that CAC providers opt to remain anonymous despite being trained due to various reasons including moral conflicts, fear of being labelled as ‘killers’, ‘murderers’, ‘terminators’ stigmatization by fellow health workers or the community.
When asked why they would not want to be known, a respondent said,
“… So, there's usually that stigma that people will put on your head saying these are people that are murdering unborn babies. Others will even call you [a] terminator.” (Clinical officer, 6 years in service)
“… Yeah, okay quiet alright we’ve had some challenges whereby some staff would be like no, in as much as I was trained I can’t do a termination because of my personal beliefs or religion.” (Registered nurse, 4 years in service)
Facilitators to the provision of Comprehensive Abortion Services
1. Trainings and mentorship
The informants described how the training in CAC made it easier for them to provide the services. They indicated that almost all the providers working in the departments were trained in CAC through external support. CAC providers felt confident with the skills to provide quality services and counselling to establish trust and confidence in the clients. However, they also felt that refresher courses were sparsely provided. When asked whether a provider was trained, the response was;
“uhmm, it was sometime back, (…), though it was in my early, early stages of my career of when I started.” ( Midwife, 8 years in service)
2. Legal framework
The HCPs perceived the existence/availability of a legal framework providing guidelines on service provision of CAC provided a favourable legal environment for them to provide the service. Some thought that the legal framework was user-friendly and protective.
“I think the legal framework is very clear and protective. Okay. Yeah, it is clearly stipulated the conditions under which an abortion can be offered. And even as you're counselling for these services, it doesn't mean that you ever come straight away, you offer the service, we counsel them [women] Okay On the indications of abortion.” (Clinical officer, 6 years in service)
However, although it was indicated that a legal framework was in place with general guidance on the provision of care, it was felt that not all the providers agreed with the guidelines due to some moral aspects. This was the same for the user of the services as the HCPs felt that there was a need to create awareness about the services.
“So once people are sensitized, they know that this service is offered in these facilities, I think we've even reduced the unsafe miscarriages to zero. So that's what we need its publication there [community]. The other factor is that now, it's those ones [women] that received the service that are able to tell their colleagues, but then they are few, so meaning that the majority of them [women] are still in the society not knowing what to do, should there be an impetus for them to discontinue their pregnancy.” (Registered nurse, 3years in service)
Respondents were conversant with the legal framework on abortion and were agreeable to service provision because they believe every patient has the right to be attended. The general feeling was that the legalization has made it possible for women to have a service provided to them in a safe environment which will help reduce the complications of unsafe abortions. Furthermore, some of the clients that come through are young and still in school hence the service would enable them to remain in school.
“The law has already been passed that it can be done in a safe setting and if the client comes to seek the stuff and all the issues surrounding the pregnancy was discussed, and the conclusion is reached, and everything is done properly, uhmm for me it is safe, unlike it is done outside and then patient comes with complications.” (Registered nurse, 4 years in service)
3. Task shifting
The task-shifting strategy was reported to be a good strategy that enabled the provision of services by HCP easier. Through task shifting, some specific tasks conducted by a medical doctor, such as pre abortal counselling, administration of medical abortion drugs, manual vacuum aspiration, and family planning services, were moved to nurses and midwives where appropriate.
“Maybe it can be improved by maybe training more providers, like maybe where the nurses, the midwives are also trained because they are always there on the ground and if more are trained maybe the service can be boosted somehow.”(Midwife, 8 years in service)
4. External support (Cooperating partners)
Financial support from external funders was reported to have been beneficial in some facilities which received the support. In addition, CAC providers narrated how their support through refresher courses, medical supplies and equipment contributed to providing services. For instance, one provider reported how previous support through incentives motivated the providers.
“I think also having materials available, cause usually CAC, IPAS [partner] used to provide us with the the the the the syringes,as well as the vacuums as well as the cannulas as so forth (…) so with them not giving us, I think work is being compromised, yeah because we do not have enough of those.” (Clinical officer, 6 years in service).