challenges in implementing comprehensive abortion care (cac)

68 Pages·2013·1.49 MB·English

COMPREHENSIVE ABORTION
CARE IN CHIBOMBO DISTRICT

JOMBO NAMUSHI
ZAMBIA

49th International Course in Health Development
September 19, 2012 – September 6, 2013

KIT (Royal Tropical Institute)
Development Policy & Practice/
Vrije University of Amsterdam
TITLE
Analysing implementation of Comprehensive Abortion Care in
Chibombo District: Barriers hindering women from accessing
services
A thesis submitted in partial fulfillment of the requirement for the degree of
Master of Public Health
By
Name: Jombo Namushi
Country: Zambia
Declaration:
Where other people’s work has been used (either from a print source,
internet or any other source) this has been carefully acknowledged and
referenced in accordance with departmental requirements.
The thesis analysing challenges in implementing Comprehensive Abortion
Care in Chibombo District is my own work.
Signature: ……………………………………………………….
49th International Course in Health Development (ICHD)
September 19, 2012 – September 6, 2013
KIT (Royal Tropical Institute)/ Vrije Universiteit Amsterdam
September 2013
Organised by:
KIT (Royal Tropical Institute), Development Policy & Practice
Amsterdam, The Netherlands
In co-operation with:
Vrije Universiteit Amsterdam/ Free University of Amsterdam (VU)
Amsterdam, The Netherlands
Contents
List of Tables page ................................... iv
List of figures Page .................................... v
Acknowledgements ............................................................................................................................... vi
List of abbreviations ............................................................................................................................ vii
Preface ....................................................................................................................................................... ix
Abstract ...................................................................................................................................................... x
Introduction .......................................................................................................................................... x
Method .................................................................................................................................................... x
Results .................................................................................................................................................... x
Conclusion: ............................................................................................................................................ x
Key words .............................................................................................................................................. x
Word count ........................................................................................................................................... x
1. INTRODUCTION ................................................................................................................................. 1
1.1. Comprehensive Abortion Care (CAC) ................................................................................ 2
1.2. Background ................................................................................................................................. 3
1.2.1. Zambia ..................................................................................................................................... 4
1.2.2. Chibombo ................................................................................................................................ 7
2. Problem Statement, Justification, Objectives & Methodology ....................................... 10
2.1. Problem Statement ................................................................................................................ 10
2.2. Justification ............................................................................................................................... 11
2.3. Objectives .................................................................................................................................. 12
2.3.1. General Objective .............................................................................................................. 12
2.3.2. Specific Objectives............................................................................................................. 12
2.4. Methodology .............................................................................................................................. 12
2.4.1. Study area ............................................................................................................................ 12
2.4.2. Study design ........................................................................................................................ 12
2.4.3. Data collection method .................................................................................................... 13
2.4.4. Search engines and terms .............................................................................................. 13
2.4.5. Inclusion criteria ................................................................................................................. 13
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2.4.6. Data analysis ....................................................................................................................... 13
2.4.8. Limitations ............................................................................................................................ 14
2.4.9. Dissemination and use of results ................................................................................. 14
3. RESULTS ............................................................................................................................................. 15
3.1. Global statistics/perspective of abortion........................................................................ 15
3.2. Abortion Laws ........................................................................................................................... 17
3.2.1. Global perspective of abortion laws ............................................................................ 17
3.2.2. Zambian abortion laws .................................................................................................... 19
3.3. Comprehensive Abortion Care (CAC) .............................................................................. 20
3.3.1. Family planning (FP) ......................................................................................................... 20
3.3.2. Safe abortion (or Legal TOP) ......................................................................................... 21
3.3.3. Post Abortion Care (PAC) ................................................................................................ 21
3.4.1. Reasons why Women may want an abortion .......................................................... 22
3.4.2 Providers and methods for unsafe abortion. ............................................................ 23
3.5. Sexual and reproductive health services in Chibombo District (all facilities) . 23
3.5.1. Family planning ................................................................................................................... 25
3.5.2. Abortion ................................................................................................................................. 26
3.5.3. Post Abortion Care (PAC) ................................................................................................ 27
3.6. Trends in uptake of CAC services during the rollout ................................................. 27
3.7. Analysing barriers to accessing CAC services .............................................................. 31
3.7.1. Supply/Health care related barriers ........................................................................... 32
3.7.2. Demand/Patient related barriers ................................................................................. 36
4. DISCUSSION ..................................................................................................................................... 40
4.1. Supply barriers ........................................................................................................................ 40
4.1.1. Availability ............................................................................................................................ 40
4.1.2. Acceptability ......................................................................................................................... 41
4.2. Demand barriers ..................................................................................................................... 41
4.2.1. Geographical accessibility ............................................................................................... 41
4.2.2. Affordability .......................................................................................................................... 42
4.2.3. Acceptability ......................................................................................................................... 42
5. CONCLUSION .................................................................................................................................... 43
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6. RECOMMENDATIONS ..................................................................................................................... 44
7. REFERENCIES ................................................................................................................................... 46
8. ANNEXES ............................................................................................................................................ 51
Annex. 1. Problem tree of determinants of Unsafe abortion .......................................... 51
Annex. 2. Countries by restrictiveness of abortion laws .................................................. 52
Annex. 3. Abortion Services from Jan to Aug 2011 ............................................................ 53
Annex. 4. Family Planning Services by type of contraceptive ........................................ 53
Annex. 5. Stock-out of contraceptives and medical abortion drugs ............................ 54
Annex. 6. Case Scenario ............................................................................................................... 55

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List of Tables page
Table 1.1. Some demographic characteristics of Zambia……………………………..4
Table 1.2. Number and types of health facilities in Zambia by region………….6
Table 1.3. Selected demographic features of Chibombo District……………………7
Table 1.4. Top Ten causes of Mortality in facilities in Chibombo District……….8
Table 2.1. Conceptual framework………………………………………………………………….14
Table 3.1. Global landscape of abortion laws……………………………………………….19
Table 3.2. Sexual and Reproductive health services and CAC coverage in the
district in all facilities………………………………………………………………………………………23
Table 3.3. Reasons for seeking Termination of Pregnancy (TOP)………………..30
Table 3.4. Clients sources of information on TOP…………………………………………30
Table 3.5. First point of seeking TOP…………………………………………………………….31

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List of figures Page
Figure 1.1. Map of Zambia……………………………………………………………………………….3
Figure 1.2. Population pyramid of Zambia, Age/sex……..……………………………….5
Figure 1.3. Zambia’s population distribution by age groups………………………….5
Figure 3.1. Regional abortion rate trends between 1995 and 2008…………….16
Figure 3.2. Comparison of region unsafe abortions between 1990 and
2008………………………………………………………………………………………………………………..16
Figure 3.3. Regional comparison of maternal deaths due to unsafe abortion
between 1990 and 2008…….………………………………………………………………………….16
Figure 3.4. Map showing global trends of unsafe abortions…………………………17
Figure 3.5. Trends of CAC services in all facilities over a three years period
(2009-2011)…………………………………………………………………………………………………..25
Figure 3.6. Trends of abortions and TOPs in CAC facilities Jan-Aug
2011……………………………………………………………………………………….. …………………….27
Figure 3.7. Age distribution of clients attended for abortion and seeking TOP
services……………………………………………………………………………………………………………28
Figure 3.8. Age and general contraceptive use in CAC facilities………………….29
Figure 3.9. Age distribution of women seeking CAC …………………………….…….29

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Acknowledgements
My heartfelt appreciation and special recognition goes to my thesis advisor
and backstopper for their valuable guidance towards this thesis. I wish to
extend my recognition to course management, all the course coordinators,
and all teachers who taught in the various modules, both local and visiting
teachers their material were an enormous source of knowledge towards this
thesis. Not forgetting the administrative secretaries, for their relentless
effort in organising the course and keeping as informed throughout the
course.
The list of all people who supported me on this journey may be too long to
exhaust, Dr Chisha (DMO, Chibombo), Dr Somwe (Head of Department
Paediatrics, UTH) and my fellow ICHD participants, to mention but a few, I
wish to say thank you for your support.
To my wife and children whom I robbed of my valuable presence to pursue
this noble career, I wish to say thank you for your continued inspiration.

Finally and most importantly, my appreciation goes to the Dutch
Government through the NUFFIC for according me a scholarship to study at
KIT in the Netherlands. I will forever be grateful to the Dutch people for this
great and rare opportunity accorded to me.

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List of abbreviations
AIDS - Acquired Immunodeficiency Syndrome

AU – African Union

BTL – Bilateral Tubal Ligation

CAC – Comprehensive Abortion Care

CSO – Central Statistical Office

D & C – Dilatation and Curettage

DHMT – District Health Management Team

DMO – District Medical Office

Et al – and others

EVA – Electrical Vacuum Aspiration

FP – Family Planning

GDP – Gross Domestic Product

GRZ – Government of the Republic of Zambia

HAC – Hospital Affiliated Health Centre

HIV – Human Immunodeficiency Virus

HMIS – Health Management Information System

ICHD – International Course in Health Development

ICPD – International Conference on Population and Development

IPAS – International Pregnancy Advisory Service

IUCDs – Intrauterine Contraceptive Devices

IUDs – Intrauterine Devices

LMIC – Lower-Middle Income Country

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MA – Medical Abortion

MDGs – Millennium Development Goals

MMR – Maternal Mortality Rate

MOH – Ministry of Health

MVA – Manual Vacuum Aspiration

NGO –Non Governmental Organisation

PAC – Post Abortion Care

RHC – Rural Health Centre

RPOCs – Retained Products of Conception

SRH – Sexual and Reproductive Health

STI – Sexually Transmitted Infection

TB – Tuberculosis

TOP – Termination of Pregnancy

TV – Television

UN – United Nations

UNICEF – United Nations International Children’s Emergency Fund

UNFPA – United Nations Fund for Population Activities (now- United
Nations Population Fund)
USD – United States American Dollar

WHO – World Health Organisation

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