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Factors Associated with Utilization of Post-Abortion Care (Pac) Services in Tanzania: a Case Study of Temeke District of Dar Es Salaam

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Factors Associated with Utilization of Post-Abortion Care (Pac) Services in Tanzania: a Case Study of Temeke District of Dar Es Salaam FACTORS ASSOCIATED WITH UTILIZATION OF POST-ABORTION CARE (PAC) SERVICES IN TANZANIA: A CASE STUDY OF TEMEKE DISTRICT OF DAR ES SALAAM By Evaline Gabriel Mcharo A thesis submitted in the fulfilment of the requirements of the award for the degree of Doctor of Philosophy in Population Studies at the Population Studies and Research Institute of the University of Nairobi November, 2016 i DECLARATION This thesis is my original work and has not been presented for a degree in any other university. Candidate: Evaline Gabriel Mcharo Signature _________________ Date ______________ This thesis has been submitted with our approval as university supervisors. Prof. Lawrence D.E Ikamari Signature _________________ Date ______________ Prof. Alfred Otieno Agwanda Signature _________________ Date ______________ ii ACKNOWLEDGMENTS First and foremost, I thank the Almighty God for providing me with strength, courage and enthusiasm to embark on this work. I would like to thank the Consortium for Advanced Research and Training in Africa (CARTA) and University of Dar es Salaam-Dar es Salaam University College of Education (UDSM-DUCE) for the financial and material support. My heartfelt appreciation goes to my supervisors, Prof. Lawrence Ikamari, Prof. Alfred Otieno Agwanda of the University of Nairobi and my external advisor, Prof. Daniel Smith of Brown University-USA for their relentless technical support, encouragement, and advice throughout my study. Their constructive criticisms brought this work this far. My thanks go to the National Institute for Medical Reserch (NIMR) for granting a permission to undertake this study in Temeke distict. I would like to thank the Regional and District Medical Officers and all government officials of Temeke and Ilala districts for permitting me to undertake the study in their health facilities. In addition, I am indebted to the management and healthcare providers who rendered me with exceptional and timely assistance during data collection. Special thanks go to Dr Adam, Dr Immanuel, Dr Mwinami, and Sister Lyimo on behalf of all the healthcare providers who participated in this study. Furthermore, I owe special thanks to the participants who provided information for this study. I thank very much the users and the non-users of PAC services who despite their health conditions accepted to participate in this study. The information they provided made this research meaningful. Special thanks go to the focus group discussion participants and key informants. Their contribution to this study is highly appreciated. iii I appreciate the tolerance of my lovely daughter Neila during my absence. It is my prayer that one day she will reach this far. I would like to thank my father Gabriel Mcharo, my mother Bertha Masao, my siblings Sophia, Samwel, Maria, Adeline, Elizabeth, Mama Jr, Daudi and our own lawyer Simon for their material and moral support. I am greatly indebted to the family of the Late Mr. Martin Anael Moshi for taking care of my daughter when I was away for my studies. Grace Moshi, Anael, Mecku, Edna, Boss, Upendo Mafude, Lucy, Juliana, Judy, Sandra, Siah, Khadija, Jane and Muddy provided moral and material support which contributed to the completion of this work. Though it was my wish for late Mr. Martin Anael Moshi to witness this achievement, I believe that whenever he is, he is celebrating my success. I will never ever forget those kind and encouraging words from him. May His Soul Rest in Eternal Peace. I am grateful to Dr. Cresencia Massawe, Dr. Anne Khasakhala, my mlamu Dr. Linda Nyondo Mipando, Elizabeth Mbwana, Dunia Othman, Philbert Mrema, and the Ubungo crew. Each of them made a unique contribution towards the successful completion of this work and they will always have a special place in my heart. My friends in Kenya, Fortunata Muthoni, Ruben and Peter, thank you for being there for me during the lonely times. I am thankful to the Watson Institute for International Studies of Brown University of USA for providing me with a placement at the institute. Thank you all for the support and the love you provided me during my stay. I sincerely thank my workmates at UDSM-DUCE and all staff members at Population Studies and Research Institute of the University of Nairobi for the support they provided me during the entire period of my study. I also acknowledge the support I received from the CARTA Cohort-2 Fellows. May God bless them in their future endeavors. iv DEDICATION I dedicate this work to my lovely daughter, Neila, for her perseverance, to my parents for valuing and advocating girl child education, to my siblings and to the Late Martin Anael Moshi, a father and a friend. v ABSTRACT This study investigated the factors associated with the use of PAC services in Temeke district of Dar es Salaam Tanzania. Specifically, the study sought to identify the characteristics of the users of PAC services and factors that facilitated and those that hindered utilization of the services. The study also investigated the perceptions of the providers and the users about the quality of PAC services. Furthermore, the study sought to establish and document the perceptions of the community on abortion and PAC services. The study was guided by the 1995 Andersen‘s framework of healthcare utilization. The design of the study was cross-sectional and quantitative and qualitative data collection methods were used. The min study approach used was qualitative for objective one, two and three which was supplemented by exit interviews to identify the characteristics of the users of PAC services. Exit- interviews, in-depth interviews, focus group discussions and direct observation were used to collect information. Purposive sampling was used to recruit the study participants. The study conducted a survey among 103 exit clients for PAC services and 16 providers in three health facilities. It conducted 10 FGDs among community members, in-depth interviews among 7 key informants and in-depth interviews among 6 women who experienced abortion complications but did not seek PAC services. Descriptive statistics were used to analyse the quantitative information while thematic analysis was used to analyse the qualitative information. About 45 percent of the users of PAC services were below 25 years. About 64.1 percent were not married, 61.3 percent did not have any formal employment while 12.2 percent were still attending to school. About half (50.5 percent) had primary education, 43.7 percent had secondary vi education and only 5.8 percent had tertiary education. Almost all the users of PAC services who participated in the study were from within Temeke district. From the analysis of the exit interviews data, the users of PAC services identified sharing of information about the health status, having received financial support from relatives and friends to carter for transport and treatment cost, availability of PAC services, privacy, short waiting time and the availability of transport as the factors that facilitated their seeking of care. In-depth interviews with the non-users of PAC services indicated that fear of being arrested by the police for having an illegal induced abortion, fear of the negative reactions by the providers and lack of money for the treatment as the main factors that hindered their utilization of PAC services from health facilities. The quality of PAC services being provided was being perceived to be good by the providers and the users. However, the high cost of the services, inadequate staff, inadequate on-the-job training, inadequate equipment and supplies and lack of privacy were some of the concerns raised by both the providers and the users of PAC services. The perceptions of the community on induced abortion were negative but their perceptions on PAC services were positive. This study concludes that PAC services can be acceptable in settings where abortion is illegal and stigmatized. Women with abortion complications will utilize PAC services regardless of their age, marital status or their socioeconomic backgrounds. Their utilization of PAC services will depend on the extent to which the services are available, well known, affordable and there is available, reliable and affordable transport. PAC services should also be of high quality. The quality of the services depends largely on adequate staff, adequate and properly functioning equipment and supplies and services that guarantee users‘ privacy. vii The study therefore recommends that measures should be taken to ensure that PAC services are known to the users, are affordable and accessible and are of high quality. Quality PAC services will entail increasing the number of health facilities offering PAC services, having adequate number of staff and having functioning equipment and supplies all the times. Providing regular on-the-job training to the providers is also important to enhance quality of the services. Privacy during the delivery of PAC services should be considered for enhancing quality and continued use of care. Raising the level of awareness about PAC services and the importance of seeking care promptly following abortion complications is important to reduce fear of being arrested by the police and fear of the negative reactions by the providers. This study did not recruit enough sample size for the non-users of PAC services in order to make generalizations. The study also did not establish the influence of the community‘s perceptions about abortion and PAC on the utilization of PAC services. Therefore, this study also recommends further research on
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