Evaluation of the capacity and quality of post- care in : a health systems, signal function approach using a health facility census

Taylor Riley1, Gerald Madziyire2, Onikepe Owolabi1, Elizabeth Sully1, Tsungai Chipato2

1- Guttmacher Institute 2- College of Health Science – Clinical Trials Research Centre (UZCHS-CTRC)

Objectives: With Ziae’s high ateal otalit ad estitie aotio las, it is ipeatie to better understand unsafe abortio ad the health sste’s ailit to teat aotio opliatios. We utilized the structure and process elements of the Donabedian quality of care model to assess the quality of post-abortion care (PAC) on a national scale. We used the signal functions approach, a widely used monitoring framework that measures service delivery, distribution and structural quality, to assess the structure dimension, and we examined the poess of ae fo oe’s health eods at a saple of these facilities.

Methods: We utilized a 2016 national census of health facilities in Zimbabwe with PAC capacity (n=227) and a prospective, facility-based 28-day survey of women seeking PAC in a nationally-representative sample of those facilities (n=1,002 PAC patients at 127 facilities). Signal functions, which are critical services that treat abortion complications, were used to classify facilities as having the capability to provide basic or comprehensive care. All facilities are expected to provide basic care, and referral level facilities (not primary care level) are designed to provide comprehensive care.

Results: We found critical gaps in the availability of PAC services; only 20% of facilities had basic capability to provide PAC and 10% of facilities had comprehensive capability. One-fourth (25%) of PAC patients were treated with the appropriate and recommended uterine evacuation technologies (manual and versus dilation & curettage) and 46% of those who had contraceptive counseling received modern contraception at discharge.

Conclusion: This is the fist atioal assesset of the Ziaea health sste’s apait to poide PAC. These findings suggest large gaps in the availability and distribution of facilities with basic and comprehensive PAC capability. These structural gaps are impacting the process of care, with most PAC patients not receiving recommended procedures. The high maternal mortality ratio in Zimbabwe behooves policy makers and researchers to focus on the health sste’s apait to peet hat ae most often preventable emergencies, such as complications from unsafe , as a way to reduce the high maternal mortality.

Introduction

Zimbabwe has one of the highest maternal mortality ratios in the world at 651 per 100,000 live births and has actually seen an increase in maternal deaths in the past two decades in contrast to the global decreasing trend [1]. remains an important cause of maternal mortality and morbidity, with approximately 9% of maternal deaths attributable to abortion [2]. There are an estimated 6.2 million unsafe abortions in Africa yearly, and one-third occur in Eastern Africa where Zimbabwe is located [3]. Abortion in Zimbabwe is highly restricted and permitted only in cases of , , fetal impairment, or whe the othe’s life is at isk [4]. Restrictive abortion laws are associated with increased abortion- related morbidity and mortality [5]. Estimates of maternal mortality attributable to abortion complications in Zimbabwe range from 6 to 23%, but these are from smaller-scale studies that are over a decade old [6,7]. The global focus on reducing maternal mortality and morbidity has focused on expansion of coverage, such as increasing facility delivery, but a growing field of scientific literature is highlighting the importance of focusing on the quality of care in order to make significant impacts on maternal mortality [8]. Since abortion is one of the main causes of maternal death, it is essential to understand the quality of abortion care in a context of high maternal mortality and restrictive abortion laws, like Zimbabwe. Complications from unsafe abortions require post-abortion care (PAC) services to treat clinical symptoms and prevent subsequent unintended . There is a substantial evidence base for the provision of PAC comprising of the clinical management of abortion complications (spontaneous and induced) using manual vacuum aspiration (MVA) and misoprostol as appropriate technologies for uterine evacuation, post-abortion contraceptive counseling and services, and task-shifting to mid-level providers [9]. Ziae’s Miist of Health and Child Care (MoHCC) has made efforts to implement these evidence- based approaches to improve PAC by updating the national PAC guidelines in 2014 [10]. The guidelines include treatment of abortion complications with misoprostol or MVA instead of (D&C) for first trimester abortions, and provision of comprehensive post-abortion family planning services [10]. However, Zimbabwe has undergone a prolonged period of economic decline resulting in potential effects on delivery, utilization and quality of health care [11]. There is a dearth of literature on measuring and evaluating the quality and capacity of abortion care, especially in a context where access to safe abortion is restricted, and there is inconsistency in how the quality of abortion care has been measured [9,12]. The Donabedian quality of care model is widely used to evaluate the quality of health care in order to improve health outcomes [13]. Within this framework, structure indicators (the setting where care is delivered) and process indicators (how care is given, i.e. following evidence based procedures) can be evaluated and manipulated in order to improve the third indicator, outcomes, which is the impact of care on the health status of the patient. Therefore, it is critical to understand the structure and process of care in order to enhance the quality of care to improve health outcomes. The Donabedian quality of care model provides a framework to assess the structural and poess idiatos of the ualit of PAC i Ziae’s health system. Structure indicators used to assess quality of abortion care have primarily focused on infrastructure [12]. A frequently used framework to assess structural quality is signal functions. Signal functions were initially developed as a shortlist of key life-saving obstetric interventions that target the most common causes of maternal mortality to describe the capacity of health facilities to provide emergency obstetric care (EmOC) [14]. They have been divided into two levels of capacity: basic and comprehensive. Primary level facilities are generally expected to have basic capacity, and referral level facilities are expected to have comprehensive capacity to treat severe cases with surgical procedures and blood transfusions. The World Health Organization (WHO) recommends 5 EmOC facilities per 100,000 population, with at least one being comprehensive [14]. Signal functions have been used to monitor service delivery trends over time, assess population access to emergency services, and explore geographical disparities [15].

The EmOC signal function approach did not include all of the essential elements for abortion care, so it was adapted in 2008 to create a framework for measuring signal functions of safe abortion care (SAC), treatment of abortion complications, and post-abortion contraception [16]. In order to make comparisons of abortion services across countries regardless of the legal status of abortion, Campbell et. al. proposed a modified approach that separated out termination of (TOP) and PAC services at basic and comprehensive levels [15]. This framework added to the family planning components by specifying more contraceptive method choices, which is in line with family planning quality of care guidelines [17,18]. They also added referral capability as a signal function for basic PAC facilities to ensure facilities have the capacity to refer patients with severe complications needing more complex interventions to higher level facilities.

The objective of this paper is to evaluate the structure and process components of quality of PAC services within the Zimbabwean health system. We used the signal functions framework to assess service delivery, distribution and structural quality of care from a census of PAC-providing facilities and we examined the poess of ae fo oe’s health eods at a saple of these facilities. This allowed us to uniquely assess gaps between potential capacity to provide quality PAC (based on availability of infrastructure) and actual evidence-based care for PAC patients (based on documented care processes). No studies have eaied the Ziaea health sste’s apailit to povide quality PAC on a national scale [19]. This health systems evaluation of PAC will allow policy makers to identify leverage points to improve quality of PAC services to reduce abortion-related maternal morbidity and mortality at the population level.

Methodology This was part of a larger project to estimate the national abortion incidence and assess the severity of post-abortion complications among PAC patients in Zimbabwe [20]. We updated the PAC signal function classification system refined by Campbell et al [15], adapted from the SAC model by Healy et al [16], to evaluate Ziae’s health sste’s apait to poide PAC. We used the 2016 Zimbabwe Health Facility Survey (HFS) to estimate the proportion of the census of 227 health facilities that can provide basic and comprehensive PAC. We also utilized individual patient-level clinical data from the Prospective Morbidity Study (PMS) to assess the quality of PAC services provided in a nationally-representative sample of health facilities. Data was collected between August and October 2016. The study was approved by the Medical Research Council of Zimbabwe, the Joint Research Ethics Committee for the University of Zimbabwe, College of Health Siees ad the Paieata Goup of Hospitals ad the Guttahe Istitute’s Institutional Review Board. Sample The HFS included all public, private and non-governmental (NGO) facilities that had the capacity to provide PAC, which was defined as having an operating theatre or if staff were trained to use misoprostol for PAC [10]. We obtained lists of all known health facilities from the MoHCC, the Health Professions Authority (where all public and private facilities are required to register), the Private Hospitals Association of Zimbabwe, the Association of Health Funders of Zimbabwe, and Population Services-Zimbabwe, a local NGO. We did not include facilities that lacked the capacity to provide PAC, individual doctors, closed or reclassified facilities. Only 63 primary health centers met the criteria for providing PAC as they were included in a 2013 operations research study conducted by MoHCC and Venture Strategies Innovations and trained to use misoprostol for PAC [19]. From this finalized list representing a census of PAC-providing facilities in Zimbabwe, a total of 227 facilities participated in the HFS, resulting in a response rate of 100% for all facilities except private hospitals, which had a 97% response rate. More details on the sampling frame can be found in Sully et al [20].

For the PMS, out of the 227 facilities in the HFS, we selected all central (n=5) and provincial (n=8) hospitals, and selected a random sample of primary health centers (30%), district hospitals (52%), private facilities (77%), and NGO facilities (68%; includes for-profit and not-for-profit facilities). Overall, 127 facilities participated out of the 133 facilities we selected, resulting in a facility-level response rate of 95%.

Table 1. Signal functions for post-abortion care (PAC) Basic Signal Functions Comprehensive Signal Functions Perform all basic functions (minus communication/referral capacity) plus: Perform removal of retained products1 Administer parenteral antibiotics Provide long-acting reversible contraceptives (LARCs): implants or IUDs Administer uterotonics Perform blood transfusion Administer intravenous fluids Surgical/laparotomy capability Provide contraceptives (condom, pills or injectables) Communication means or referral capacity 1 Includes dilation & curettage (D&C), MVA or EVA, and misoprostol for primary health centers.

Data sources Health facility survey (HFS) with health providers Information about the available signal functions indicators at health facilities was collected through interviews with providers at each facility who were selected based on their knowledge of PAC services at their facility. We collected information on facility infrastructure, availability and functionality of supplies and equipment, PAC caseloads, treatment procedures, post-abortion contraceptive counseling, and training for PAC. The six basic signal functions and eight comprehensive signal functions are presented in Table 1. We classified that a facility had the capability to perform removal of retained products (including D&C, MVA, EVA or misoprostol); administer antibiotics, uterotonics, and intravenous fluids; or perform blood transfusions if the facility reported these as a common treatment procedure for their PAC patients. We considered a facility to have referral communication capacity if they reported commonly having a telephone/radio communication for patient services or an ambulance to transport patients to a higher level facility. Facilities that reported an available and functional operating room were considered to have surgical/laparotomy capability. If facilities reported at least one short acting method out of condoms (male or female), pill or injectables, they were coded to have the capacity to provide short acting reversible contraceptive (SARC) methods. Facilities that reported providing IUDs or implants to PAC patients were considered to have the capacity to provide long acting reversible contraceptive (LARC) methods. We did not capture family planning provision seven days a week and that the facility is open 24/7 with at least one health professional on duty as the Campbell signal functions classification system uses [15]. These questions also did not specify a specific time frame.

Prospective morbidity study (PMS) of women seeking post abortion care We collected information from PAC patients and their providers on complications from spontaneous and induced abortions treated in health facilities in the 28-day study period. This Prospective Morbidity Methodology was developed by the World Health Organization (WHO )[21], modified by Ipas [22–26], and further refined by the Guttmacher Institute [27,28]. All women presenting with incomplete, inevitable, missed, complete, or septic abortion during the study period were eligible for inclusion. We collected information on socio-demographics, reproductive health-related characteristics and delays in seeking care from women. We also gathered information from their providers on the oa’s presenting clinical symptoms, treatment of complications, and post-abortion contraceptive counseling. Other data sources

The projected total population numbers for 2016 are from the Zimbabwe National Statistics Age’s Population Projections Thematic Report [29]. The WHO recommends 5 EmOC facilities per 500,000 population with at least one providing comprehensive care. Based on the total population figure of 14,480,224, Zimbabwe requires 116 facilities with the capability to provide basic PAC services and 29 facilities providing comprehensive PAC to meet the needs of the population. Results

Table 2. Structural indicator measurements of PAC signal functions in health facilities for theoretical capacity, by type of facility Facility Type Primary Private and Health Public NGO Total Centers Hospitals Facilities Basic Signal Functions Removal of retained products1 76% 36% 96% 83% Parenteral antibiotics 71% 36% 87% 79% Uterotonics 44% 46% 41% 47% Intravenous fluids 61% 49% 69% 61% Contraceptives (condom, pills or injectables) 87% 97% 86% 79% Communication means or referral capacity 93% 85% 95% 98% Comprehensive Signal Functions2 Long-acting reversible contraceptives (LARCs): implants or IUDs 81% -- 83% 77% Blood transfusion 38% -- 49% 21% Surgical/laparotomy capability 69% -- 89% 39% 1 Includes dilation & curettage (D&C), MVA or EVA, and misoprostol for primary health centers. 2 Comprehensive facilities must have all of the basic signal functions (excluding referral capacity) plus at least one long-acting contraceptive method (IUDs or implants), blood transfusion and surgical capability. Primary health centers were not included in the denominator for national comprehensive signal functions.

Structural indicators of quality of post-abortion care This analysis evaluated the structure and process components of the quality of PAC in all PAC-providing facilities in Zimbabwe. Table 2 presents the signal function criteria for the theoretical capacity to provide basic and comprehensive PAC services, and the proportion of facilities nationally and by facility type that met each of those criteria. Based on MoHCC designations, all facilities are expected to have at least basic capacity, and all facilities except primary health centers are designed to have comprehensive capacity for emergency PAC. Just over one-third (36%) of primary health centers had the capacity for removal of retained products and provided parenteral antibiotics. Less than half (41-47%) of facilities at each facility level had the capacity to provide uterotonics (Table 2). About half of primary health centers (49%) had the capacity to provide intravenous fluids, followed by 61% of private and NGO facilities, and 69% of public hospitals. For the comprehensive signal functions, just over one-third (38%) of all facilities expected to have comprehensive capacity were capable of blood transfusions. Most public hospitals had surgical/laparotomy capacity (89%) but only 39% of private and NGO facilities had surgical capacity.

Figure 1. Proportion of facilities that have basic and comprehensive PAC capability nationally and by facility type, Zimbabwe 2016

National

Primary Health Centers

Public Hospitals

Private and NGO Facilities

0% 20% 40% 60% 80% 100%

Basic PAC Comprehensive PAC

Nationally, only 20% of all PAC providing facilities had basic PAC capability, and 10% of facilities designed to have comprehensive capacity actually did (Figure 1). Three out of ten private and NGO facilities had basic PAC capability, followed by 23% of public hospitals and 5% of primary health centers. Fourteen percent of public hospitals and 3% of private and NGO facilities had comprehensive PAC capability (Figure 1). Table 3 presents the number of facilities meeting the recommended basic and comprehensive levels according to signal functions performance. Only 46 facilities of the 116 recommended met the basic criteria (40%), and 16 facilities of the recommended 29 (55%) achieved the comprehensive designation (Table 3). The proportion of facilities that met recommended levels varied by province with 14% of facilities meeting basic levels in Midlands and up to 69% in Masvingo. There were no comprehensive facilities in the provinces of , Matabeleland North and Midlands.

Table 3. Recommended1 and actual number of facilities with basic and comprehensive PAC capability, nationally and by province, Zimbabwe 2016 Basic Comprehensive

Proportion of Proportion of facilities facilities meeting meeting recommend recommend Recommended Actual levels Recommended Actual levels National 116 46 40% 29 16 55% Bulawayo 6 1 17% 1 0 0% 19 10 53% 5 1 21% Manicaland 16 8 51% 4 2 51% Mashonaland Central 10 3 29% 3 1 39% Mashonaland East 12 2 17% 3 1 34% Mashonaland West 13 8 60% 3 3 90% Masvingo 13 9 69% 3 7 215% Matabeleland North 7 2 30% 2 0 0% Matabeleland South 6 1 17% 1 1 67% Midlands 14 2 14% 4 0 0% 1 WHO recommends 5 facilities per 500,000 residents, with at least one being comprehensive

Table 4. Process indicators of quality of post-abortion care using prospective data from PAC patient's case files, by facility type and nationally, Zimbabwe 2016 Total Facility Type

Weighted Primary Private % N Health Public and NGO Centers Hospitals Facilities

Proportion of PAC procedures performed with appropriate technology 1 1039 25% 30% 24% 30% First trimester 685 27% 30% 25% 33% Second trimester 346 22% 23% 21% 16%

Proportion of PAC patients who received contraception counseling at discharge 2 1230 94% 100% 94% 92% Of those counseled, proportion of PAC patients who received modern contraception at discharge 1147 46% 61% 43% 67% 1 The WHO recommends misoprostol, manual vacuum aspiration (MVA), or electric vacuum aspiration (EVA) for first trimester procedures and dilatation and evacuation (D&E) and misoprostol for second trimester procedures

2 Out of all PAC patients who had been discharged at time of interview (2% of PAC cases, or 20 cases, had not yet been discharged at time of interview).

Process indicators of quality of post-abortion care

Table 4 presents indicators to evaluate the process of care utilizing prospective data fo PAC patiet’s case files. Overall, only one out of four PAC patients received the recommended PAC procedure performed with the appropriate technology (Table 4). Out of PAC patients presenting to the facility in the first trimester, 27% were treated with the appropriate technology (Table 4). The proportion of PAC procedures with the appropriate technology was slightly less for patients in the second trimester (22%). Across facility levels, the lowest proportion of PAC procedures using the appropriate technology in the first trimester was in public hospitals (25%), where the majority of patients were seen (Table 4). The proportion of PAC procedures performed with appropriate technology in the second trimester were lower in all facility levels compared to the first trimester procedures, the lowest of which was in private and NGO facilities (16%). A majority of PAC patients (94%) who had already been discharged at time of interview received contraceptive counseling (Table 4). Among those who received contraceptive counseling, almost half (46%) received modern contraception at discharge. Three out of five PAC patients at primary health centers (61%) who were counseled received modern contraception and 43% of PAC patients at public hospitals who were counseled received modern contraception (Table 4).

Figure 2. Proportion of PAC patients who recieved evidence- based PAC procedures in basic and comprehensive PAC facilities, Zimbabwe 2016

100%

80%

60%

40%

20%

0% Appropriate technology, Appropriate technology for first Appropriate technology for regardless of trimester trimester second trimester

Basic Comprehensive

Combining the sigal futios failit lassifiatios ad the pospetie data fo PAC patiet’s ase files, we analyzed the treatment received by PAC patients seen in the facilities that were classified as having basic or comprehensive capability. Less than one-third of all PAC patients (31%) received treatment in a facility that met all the signal functions criteria for basic PAC capability (data not shown). One out of five PAC patients (20%) was treated in a facility with comprehensive capability (data not shown). Figure 2 shows the proportion of PAC patients treated with the appropriate PAC technology in basic and comprehensive PAC facilities. Just over one-third (34%) of PAC patients in basic capacity facilities received the appropriate PAC treatment regardless of trimester, which was higher than the 18% in comprehensive facilities (Figure 2). A higher proportion of PAC patients in their first trimester who were seen in basic facilities received the appropriate PAC procedure (38%) compared to just 14% in comprehensive facilities (Figure 2). Less than one-third of PAC patients (27%) seeking treatment in their second trimester received the appropriate technology in both basic and comprehensive facilities (Figure 2). Discussion and recommendations The objective of our study was to use a health systems approach to evaluate the structural and process components of the quality of PAC and understand national population level exposure and access to essential PAC services. We applied the signal functions approach to assess the basic and comprehensive PAC capability of health facilities. Overall, only 20% of all PAC providing facilities have basic PAC capability in Zimbabwe. Only one in ten higher level facilities designated by the MoHCC to provide comprehensive care actually have the capacity to do so. This PAC signal functions framework was first applied in Zambia where only 3% of facilities fulfilled basic PAC criteria and less than 1% fulfilled comprehensive PAC criteria [15]. The Zambian scenario required stricter staffing criteria that were not included in the Zimbabwe analysis, which explains some of the lower proportions. However, both country studies show the health sste’s etee lak of apailit to teat ad peent post-abortion complications to reduce abortion- related maternal mortality. The disparities in PAC capacity by level of facility is important to evaluate when taking a health systems approach. Just over one-third (36%) of primary health centers have the capacity to evacuate the uterus, yet they are intended to be the first point of care for women in rural areas, where the majority of the Zimbabwean population lives [1]. Rural women have significantly higher odds of developing higher severity post-abortion complications when compared to urban women in Zimbabwe [30]. Therefore, it is important for primary health centers to be equipped with appropriate uterine evacuation technologies to avoid delays in treatment associated with referring patients to other facilities. If a patient is referred or goes directly to higher level facilities for treatment, these facilities must have the capability to treat severe complications in order to prevent abortion-related maternal mortality. Our analysis shows that only 38% of facilities have the capacity for blood transfusion services, which is vital for women with hemorrhage and/or anemia, both common post-abortion complications. In addition, IV antibiotics must be available in all facilities as they form the first line of resuscitation for patients who have experienced severe hemorrhage or sepsis. It is also helpful to evaluate PAC capability based on the actual population needs and distribution. Only 46 facilities have basic PAC capacity out of the 116 that are recommended based on the population size. There are disparities among provinces meeting recommended levels of basic capability based on their population sizes. The proportion of facilities with actual basic capacity compared to recommended levels is lowest in Bulawayo, the second largest city in Zimbabwe, and Matabeleland South and Midlands, which are more rural provinces. This suggests that low PAC capacity is not just an issue in rural, isolated areas as is often thought, but that both urban and rural areas in Zimbabwe are lacking population coverage for PAC. The availability and distribution of comprehensive PAC facilities is slightly closer to recommended levels with sixteen out of the recommended 29 facilities (55%) having comprehensive PAC capability, and these proportions vary greatly by province. Bulawayo, Matabeleland North and Midlands have no facilities that meet all of the criteria to provide comprehensive PAC. This means that women in these provinces with life-threatening post-abortion complications are receiving inadequate treatment at facilities in those provinces or are referred out to facilities in other provinces. Either of these scenarios could result in the increased likelihood of an abortion-related maternal death. It is common across signal functions assessments that facilities meet or are closer to the comprehensive benchmark because the requirement for the population is lower (1 per 500,000) than the basic requirement [31]. It appears some of these gaps in structural quality of care illuminated using the signal functions approach translate into poor delivery of PAC services based on oe’s health eods at a saple of these facilities. Only one in four PAC patients received the recommended evidence-based PAC procedure, regardless of trimester. In addition, almost half (46%) of PAC patients who received contraceptive counseling also received modern contraception at discharge. Providing voluntary contraceptive services for PAC patients to prevent future unintended pregnancies is an essential component of PAC. Other studies in Zimbabwe have found that facilities should have free and comprehensive contraception services within the wards where patients are admitted before discharge as going to another unit in the hospital for contraceptive methods is a substantial uptake barrier for many PAC patients [18,32]. While a minority of PAC patients received care at facilities meeting either the basic or comprehensive criteria, among those who did, most did not receive evidence-based PAC procedures. This suggests that even if a health facility has the theoretical capacity to provide basic or comprehensive PAC as documented in signal functions, there are still barriers to providing quality, evidence-based care. These barriers likely stem from a weakened health system that is not able to provide the training, supplies, management and commodities required for facilities to provide high quality care. Over half of facilities (55%) reported stock- outs of misoprostol in the past three months before the survey, and almost all primary health centers reported misoprostol stock-outs (93%) (data not shown) [20]. On average, less than 2 providers in primary health centers have been formally trained to use misoprostol as a PAC procedure (data not shown). These results are further evidence that a health systems approach must address all of the system building blocks including workforce, service delivery, medical technology, and more, instead of just focusing on one component at a time, in order to improve quality of care and health outcomes at the population level [33]. Our study has several limitations. The measurement of availability and functionality of PAC services and medicines is self-reported from the health provider in the facility and not visually confirmed by the interviewer, which could lead to an overestimation of capability. The signal functions criteria questions did not ask about availability and functionality within a time frame like signal functions assessments that typically use 90 days. Therefore, the signal functions levels are most likely an overestimate of capability. In addition, for the data drawn from the prospective survey of PAC patients, these women were interviewed at discharge so it is possible they could have been given modern contraception after the interview, and therefore we could have underestimated the proportion of PAC patients receiving modern contraception. The WHO benchmark of 1 comprehensive care facility per 500,000 residents is likely an underestimate since the recommendation is based on the assumption that 15% of pregnancies will result in complications [15]. The populatio at isk ad i eed of PAC could be substantially different than women with pregnancies that result in obstetric complications, and therefore it might be beneficial to re- assess the recommended and actual levels using a benchmark that is more related to the population at risk of post-abortion complications who are in need of PAC. Nevertheless, this study offers an innovative framework to evaluate the structural and process components of quality of care on a national scale. The study design of a census of PAC providing facilities ad a pospetie stud of PAC patiets’ teatet ad epeiees in a nationally-representative sample of these facilities allows for a direct comparison of theoretical capacity using signal functions and the process of care PAC patients actually receive in the same facilities. This analysis illuminated the gap between having the potential capacity to provide PAC and the actual PAC provision in facilities that is not quality, evidence-based care. This health systems evaluation has shown that policies and programs aiming to improve the availability and quality of PAC must take a health systems approach and recognize the various commodities, training, management, and financing needs of the health system. Conclusion

This analysis provides the first-ever national evaluation of the quality of PAC in Zimbabwe and highlights the critical gaps in access, distribution and availability of essential PAC services. The Zimbabwe MoHCC should improve PAC capacity through training health workers in providing the appropriate evidence- based care and equipping facilities with the necessary equipment and drugs to provide PAC. Studies on addressing maternal mortality and morbidity often focus on measurement and causes, but understanding the capacity of a health system to provide emergency care is an essential way of reducing mortality. Improving the provision of PAC services is critical in reducing the high levels of maternal morbidity and mortality related to abortion complications. The elevated maternal mortality ratio in Zimbabwe requires policy makers and researchers to focus on the health sste’s apait to peet hat ae ost ofte preventable emergencies, such as complications from unsafe abortions, as a way to reduce the high maternal mortality.

References

1. Zimbabwe National Statistics Agency, ICF International. Zimbabwe Demographic and Health Survey 2015: Final Report. 2016.

2. Global Burden of Disease Study 2016. Global Burden of Disease Study 2016 (GBD 2016) Healthcare Access and Quality Index Based on Amenable Mortality 1990-2016. In: Institute for Health Metrics and Evaluation (IHME) [Internet]. 2018 [cited 3 Jan 2018]. Available: http://ghdx.healthdata.org/gbd-results-tool

3. Ganatra B, Gerdts C, Rossier C, Johnson BR, Tunçalp Ö, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet. 2017;S0140-6738: 31794–4. doi:10.1016/S0140-6736(17)31794-4

4. Zimbabwe Termination of Pregnancy Act [Chapter 15:10] [Internet]. 1977. Available: http://www.parlzim.gov.zw/acts-list/termination-of-pregnancy-act-15-10

5. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. The Lancet. 2016;388: 258–267. doi:10.1016/S0140-6736(16)30380-4

6. Fawcus S, Mbizvo M, Lindmark G, Nystrom L. A community-based investigation of causes of maternal mortality in rural and urban Zimbabwe. Cent Afr J Med. 41: 105–113.

7. Ministry of Health and Child Welfare Zimbabwe, UNFPA Zimbabwe, Munjanja S, Nystrom L, Nyandoro M, Magwali T. The Zimbabwe Maternal and Perinatal Mortality Study. 2007. 8. Kruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RMK, Langer A. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Health. 2016;4: e845–e855. doi:10.1016/S2214-109X(16)30180-2

9. Huber D, Curtis C, Irani L, Pappa S, Arrington L. Postabortion Care: 20 Years of Strong Evidence on Emergency Treatment, Family Planning, and Other Programming Components. Glob Health Sci Pract. 2016;4: 481–494. doi:10.9745/GHSP-D-16-00052

10. Zimbabwe Ministry of Health and Child Care, Chipato T. National Guidelines for Comprehensive Abortion Care in Zimbabwe, 2nd edition. 2014.

11. Zimstat (Zimbabwe National Statistics Agency). Poverty and Poverty Datum Line Analysis in Zimbabwe 2011/12. Harare: Zimbabwe National Statistics Agency; 2013.

12. Dennis A, Blanchard K, Bessenaar T. Identifying indicators for quality abortion care: a systematic literature review. J Fam Plann Reprod Health Care. 2017;43: 7–15. doi:10.1136/jfprhc-2015-101427

13. Donabedian A. The Quality of Care: How Can It Be Assessed? JAMA. 1988;260: 1743–1748. doi:10.1001/jama.1988.03410120089033

14. UNICEF, WHO, UNFPA. Guidelines for monitoring the availability and use of obstetric services [Internet]. United Nationas Children Fund; 1997. Available: https://www.unicef.org/health/files/guidelinesformonitoringavailabilityofemoc.pdf

15. Campbell OMR, Aquino EML, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth. 2016;16: 105. doi:10.1186/s12884-016-0872-5

16. Healy J, Otsea K, Benson J. Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion care services. Int J Gynecol Obstet. 2006;95: 209–220. doi:10.1016/j.ijgo.2006.08.002

17. Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann. 1990;21: 61–91.

18. Jain A, Bruce J, Mensch B. Setting standards of quality in family planning programs. Stud Fam Plann. 1992;23: 392–395.

19. Zimbabwe Ministry of Health and Child Care, Venture Strategies Innovations. Expanding Access to Postabortion Care in Zimbabwe through Integration of Misoprostol. Harare: Zimbabwe Ministry of Health and Child Care; 2013.

20. Sully E et al. The incidence of induced abortion in Zimbabwe. forthcoming.

21. Figà-Talamanca I, Sinnathuray TA, Yusof K, Fong CK, Palan VT, Adeeb N, et al. Illegal Abortion: An Attempt to Assess its Cost to the Health Services and its Incidence in the Community. Int J Health Serv. 1986;16: 375–389. doi:10.2190/BJ4F-9KJN-MFAL-6X22 22. Fetters T. Prospective approach to measuring abortion-related morbidity: individual-level data on postabortion patients. Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity: A Review, New York: Guttmacher Institute. New York: Guttmacher Institute; 2010. pp. 135–146.

23. Gebreselassie H, Gallo MF, Monyo A, Johnson BR. The magnitude of abortion complications in Kenya. BJOG Int J Obstet Gynaecol. 2005;112: 1229–1235.

24. Levandowski BA, Pearson E, Lunguzi J, Katengeza HR. Reproductive health characteristics of young Malawian women seeking post-abortion care. Afr J Reprod Health. 2012;16: 253–261.

25. Jewkes R, Brown H, Dickson-Tetteh K, Levin J, Rees H. Prevalence of morbidity associated with abortion before and after legalisation in . BMJ. 2002;324: 1252–1253.

26. Rees H, Katzenellenbogen J, Shabodien R, Jewkes R, Fawcus S, McIntyre J, et al. The epidemiology of incomplete . National Incomplete Abortion Reference Group. South Afr Med J Suid-Afr Tydskr Vir Geneeskd. 1997;87: 432–437.

27. Gebreselassie H, Fetters T, Singh S, Abdella A, Gebrehiwot Y, Tesfaye S, et al. Caring for women with abortion complications in Ethiopia: national estimates and future implications. Int Perspect Sex Reprod Health. 2010; 6–15.

28. Chae S, Kayembe P, Philbin J, Mabika C, Bankole A. The Incidence of Induced Abortion in Kinshasa, Democratic Republic of Congo, 2016. Press Plos One.

29. Zimbabwe National Statistics Agency (ZIMSTAT), UNFPA. Population Projections Thematic Report. Harare: ZIMSTAT; 2015.

30. Madziyire MG, Polis CB, Riley T, Sully EA, Owolabi O, Chipato T. Severity and management of postabortion complications among women in Zimbabwe, 2016: a cross-sectional study. BMJ Open. 2018;8: e019658. doi:10.1136/bmjopen-2017-019658

31. Paxton A, Bailey P, Lobis S, Fry D. Global patterns in availability of emergency obstetric care. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2006;93: 300–307. doi:10.1016/j.ijgo.2006.01.030

32. Johnson BR, Ndhlovu S, Farr SL, Chipato T. Reducing Unplanned Pregnancy and Abortion in Zimbabwe through Postabortion Contraception. Stud Fam Plann. 2002;33: 195–202.

33. WHO | Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. In: WHO [Internet]. [cited 28 Mar 2018]. Available: http://www.who.int/healthinfo/systems/monitoring/en/