Study Contexts
This was a multi-country study to assess the preparedness of public health facilities to deliver PAC services in Burkina Faso, Kenya and Nigeria. The three countries offer both similar and dissimilar contexts for investigating quality of PAC. For instance, abortion is legally restricted in all three countries and permitted only to save life or preserve health of a woman [8, 23]. All three countries report high incidences of unsafe abortion [10, 11, 14]. Burkina Faso (French-speaking country in West Africa) was among the first countries in SSA that changed its law in the post-ICPD period from total prohibition to allowing abortion to preserve a woman’s health [28]. Nigeria presents a peculiar case where abortion laws vary by jurisdiction with about three legal systems applicable to abortion: the penal code applicable in the northern states, the criminal code in the southern states and across the other states; while Sharia penal legislation is applicable in twelve Northern states [25, 26]. None of the three legal codes permits abortion except to save the life or health of the woman. Under the penal code, an offending health provider and woman may be imprisoned for fourteen and seven years respectively. Kenya’s 2010 constitution opened-up the grounds for access to safe abortion services as an emergency treatment to preserve the life or health of the mother, a provision that did not exist before [9]. Any other reasons inconsistent with the law are criminalized under the penal code, leading to widespread stigma and fear [30]. More recently in 2019, the Kenyan high court outlawed action by the Ministry of Health to withdraw the standards and guidelines for reducing maternal mortality due to abortion [31]. These contexts therefore offer worthy contexts to examine the preparedness of their health facilities to provide PAC services.
Study design and population
A cross-sectional survey was conducted among a representative sample of primary, secondary and tertiary health facilities in the aforementioned countries. Health system across the three countries is organized according to hierarchical levels. Health facility levels are generally categorized as primary, secondary and tertiary-levels. Primary health facilities are the first point of contact for the majority of community members’ health needs, and include community facilities, dispensaries and clinics. In Kenya, primary-level facilities handle the Kenya Essential Package for Health (KEPH), which encompass activities related to health promotion, preventive care, and curative services. Secondary facilities are referral facilities for primary-level hospitals and are mainly sub-regional and regional facilities. They undertake curative and rehabilitative care and address a limited extent of preventive care and health promotion. Tertiary facilities are mainly national referral and teaching hospitals. All health facilities capable of conducting normal deliveries were included in our sample frame. Data was collected in facilities over a 30-day period between November 2018 and February 2019.
Sampling and recruitment
A two stage stratified sampling procedure was used in each country, that is, a) the highest sub-national administrative units (i.e. counties in Kenya, states in Nigeria and regions in Burkina Faso), and b) the levels of health facilities. At the first stage, in each country, a random sample of six regions, counties or states was drawn, and excluding the administrative unit hosting the national capital regions/cities – i.e. Centre in Burkina, Nairobi in Kenya, and Abuja – Federal Capital Territory (FCT) in Nigeria. Thereafter, the capital regions/cities were added to the regions purposely to make seven regions/counties/states in each country.
The selected administrative units included, Burkina Faso (seven regions from the 13: Boucle du Mouhoun, Cascades, Centre, Centre-Ouest, Centre-sud, Haut-Bassins, and Nord); Kenya (seven counties from 47: Garissa, Kajiado, Kiambu, Laikipia, Mandera, Migori, and Nairobi); Nigeria (six states plus the federal capital territory (FCT) from 36: Anambra, Bauchi, Cross-River, Edo, Kogi, Kano and FCT (Abuja).
At the second stage, an updated master list of all public health facilities in the different sub-national units was obtained from government records. Burkina Faso and Nigeria’s list were updated up to July 2018 while Kenya was updated in February 2018. A requisite sample of facilities in each country was determined using a formula for known populations and known proportion estimates by: ∆=z√ ((p (1-p))/n).
To solve for n we made it the subject: \((n={\left(\frac{z}{\varDelta }\right)}^{2}p(1-p\left)\right)\), and assumed a confidence interval of 95%, with z as 1.96, and \(\varDelta\)as 0.05. In all cases, the known estimate p represented the proportion of facilities capable of providing PAC contraceptive counselling, which was the lowest measure for quality of PAC in Kenya (19.4%) and Nigeria (16%) [16, 30]. Because we did not find any recent estimate in Burkina Faso, we used the 50% proxy in order to generate the maximum sample size possible. These calculations yielded the number of facilities required for each country, and upon accounting for a response rate of approximately 93%, the estimated sample size of facilities was determined as follows: 414 in Burkina Faso, 259 in Kenya, and 223 in Nigeria.
The sample of health facilities was allocated to each of the seven administrative units in each country depending on the population of eligible facilities in a specific region/county or state. Eligible facilities were those that could provide normal delivery services, were publicly owned (government owned) and operational at the time of survey. As such, we excluded some specialized facilities including mental and spinal hospitals as well as military and prison hospitals known not to offer services to the public. Our focus on public health facilities is because government investments in health services primarily go to these facilities. During the survey, some facilities were dropped and replaced with similar facilities within the same locality, due to insecurity and travel inaccessibility. In addition, sampled facilities that declined to participate in the study were replaced with similar facilities from the sampling frame, which had been identified a priori.
Data collection
Trained field workers visited each eligible facility and administered the signal functions questionnaire which had been adopted from previous versions [22, 31]. The questionnaire were further refined to the contexts following extensive discussions with experienced obstetricians and gynecologists in each country. Questionnaires included details on availability of key equipment, supplies and commodities, staffing and staff training, facility operation hours and ability to perform various sexual and reproductive health services. Uniform tools were used across all countries. However, some aspects were adapted to fit in national standards (e.g. facilities categorizations). The tools were pre-tested to enhance conceptual clarity and logical flow. At large referral hospitals, respondents were the head of the obstetrics and gynecology department, or a key obstetrician gynecologist working in the facility. However, at lower level facilities, a nurse, a midwife or another health worker who was knowledgeable on PAC services provided in the facility was interviewed. The quantitative data were collected using tablets and hosted on the SurveyCTO platform. Completed and verified data were uploaded unto the APHRC cloud server for safe storage. Spot-checks were performed on 5% of the sample by the lead for each country.
Data analysis
Quantitative data was analyzed using Stata Software, version 15. Exploratory analysis was done to summarize response rates of health facilities by levels and administrative units. To describe the capacity of health facilities to deliver PAC services, we constructed composite or aggregate indicators of signal functions to provide basic and comprehensive PAC using a signal functions approach. By calculating the availability of specific health interventions that are key to PAC—i.e., the signal functions—we measure the capacity for, and quality of, PAC from a health systems perspective. We do this by summating or combining sets of indicators that constitutes the two delineated levels of care - basic and comprehensive PAC, that roughly correspond to care that should be provided at both the primary level and at the referral level hospitals respectively (Box 1). We also explored another level of analysis, which included developing case scenarios by excluding some PAC signal functions to have a less restrictive criterion at various stages. At first, we analyzed with all PAC signal functions for each facility levels. Secondly, we excluded the availability of staff capable of conducting normal deliveries, thirdly, we excluded - staff with delivery capabilities; having a referral capacity; availability of short and long-acting, or permanent family planning methods. At the fourth stage. We examined PAC capability by excluding the ability of a facility to conduct referrals (through having a vehicle fueled). “Capacity” or “preparedness” was conceptualized as ability of health facilities to deliver services based on signal function indicators [34]. Proportions of facilities capable of delivering basic and comprehensive PAC were generated.