Factors Associated With Utilization of Post-abortion Care (Pac)

223 Pages·2016·1.88 MB·English

by  Mcharo Evaline, Gabriel

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

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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 ______________

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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.

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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.
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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.

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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
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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.
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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 these areas.

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TABLE OF CONTENTS
DECLARATION........................................................................................................................... ii
ACKNOWLEDGMENTS ........................................................................................................... iii
DEDICATION................................................................................................................................v
ABSTRACT .................................................................................................................................. vi
LIST OF TABLES ..................................................................................................................... xiv
LIST OF FIGURES .....................................................................................................................xv
ABBREVIATIONS AND ACRONYMS .................................................................................. xvi
CHAPTER ONE: GENERAL INTRODUCTION .....................................................................1
1.1 Introduction ................................................................................................................................1
1.2 Statement of the Research Problem ...........................................................................................4
1.3 General Objective ......................................................................................................................6
1.4 Research Questions ....................................................................................................................6
1.5 Study Objectives ........................................................................................................................6
1.6 Study Justification ......................................................................................................................7
1.7 Scope and Limitations of the Study ...........................................................................................9
1.8 Organization of the Thesis .......................................................................................................11
CHAPTER TWO: THE CONTEXT OF THE STUDY ...........................................................14
2.1 Introduction ..............................................................................................................................14
2.2 Population Size and Composition ............................................................................................14
2.3 Reproductive Health Situation .................................................................................................15
2.4 Induced Abortion .....................................................................................................................16
2.4.1 Causes of Induced Abortion ..........................................................................................17
2.4.2 Morbidity and Mortality Associated with Induced Abortion ........................................19
2.5 Provision of PAC Services.......................................................................................................20
2.5.1 Policies and Programs on PAC Services .......................................................................22
2.6 The Structure of the Health Care Delivery in Tanzania ..........................................................23
2.7 Temeke District ........................................................................................................................24
2.7.1 Population ......................................................................................................................24
2.7.2 Economy ........................................................................................................................24
2.7.3 Literacy Level ................................................................................................................25
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2.7.4 Health Services ..............................................................................................................25
2.8 Conclusion ...............................................................................................................................26
CHAPTER THREE: LITERATURE REVIEW.......................................................................27
3.1 Introduction ..............................................................................................................................27
3.2 Abortion and Maternal Mortality .............................................................................................27
3.3 The Origin and Rationale of PAC Services .............................................................................29
3.3.1 Quality PAC Services ....................................................................................................31
3.4 Empirical Studies on Factors Influencing Utilization of PAC Services ..................................32
3.4.1 Individual Level Factors ................................................................................................33
3.4.2 Community Level Factors .............................................................................................41
3.4.3 Health System Factors ...................................................................................................44
3.5 Theories and Models on Health-Seeking Behaviour and Utilization ......................................49
3.5.1 Deterministic Models ....................................................................................................49
3.5.2 Pathway Models ............................................................................................................51
3.6 Conceptual Framework ............................................................................................................53
3.7 Operational Framework ...........................................................................................................54
3.8 Summary of the Literature Review ..........................................................................................55
3.9 Definition of Key Terms ..........................................................................................................57
CHAPTER FOUR: METHODOLOGY ....................................................................................60
4.1 Introduction ..............................................................................................................................60
4.2 The Design of the Study ..........................................................................................................60
4.2.1 The Study Approach ......................................................................................................61
4.3 The Study Area and Justification .............................................................................................63
4.4 The Study Population, Inclusion and Exclusion Criteria .........................................................64
4.5 Sampling Procedures ...............................................................................................................66
4.5.1 Criterion Sampling ........................................................................................................67
4.5.2 Snowball Sampling ........................................................................................................68
4.6 The Sample Size ......................................................................................................................68
4.7 Data Collection Instruments ....................................................................................................69
4.7.1 Exit-Interviews ..............................................................................................................69
4.7.2 In-Depth Interviews .......................................................................................................70
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