The Quality of Postabortion Care in Tanzania: Service Provider Perspectives and Results From a Service Readiness Assessment.

Abstract

In 2015, the government of Tanzania launched an effort to strengthen the quality of postabortion care (PAC), an integrated health service that includes treatment for abortion complications and provision of family planning counseling and voluntary services, in 25 facilities in mainland Tanzania and in Zanzibar. To help guide the government's initiative, we conducted a mixed-method study in 2016 using health facility surveys and in-depth interviews with health care workers that offer PAC. Surveys of the 25 facilities assessed the current use of services and readiness to deliver them. Provider performance in PAC was assessed through direct observation of client-provider interactions. In-depth interviews (IDIs) with 30 staff from the facilities provided qualitative information on priorities for PAC quality improvement. In the 6 months preceding the study, 2,175 PAC clients sought care at the facilities. Of these PAC clients, 55% chose a family planning method, of whom 6% chose a voluntary long-acting reversible contraceptive. The median facility PAC readiness scores were 45% for health centers, 49% for district hospitals, and 61% for regional referral hospitals. Direct observations of manual vacuum aspiration provision for PAC revealed that providers implemented, on average, 69% of the critical clinical steps. For misoprostol provision, PAC providers implemented, on average, 42% of the critical steps. Multilevel influences affected PAC providers' work, often adversely, by shaping their confidence in their technical competency, confusing their role as health care workers and as clients' peers, and coloring their attitudes toward clientele. The PAC providers also felt that their ability to implement their responsibilities was shaped by lapses in essential support and functionality of the health care system, as well as by social and cultural norms. Technical assistance approaches that blend training, clinical quality improvement, systems strengthening, and social interventions that address demand-side barriers are needed to ensure providers achieve their potential and are able to deliver high-quality PAC.