Enhancing capacity of Zimbabwe’s health system to reduce abortion related maternal deaths

Zimbabwe has made tremendous progress in reducing maternal mortality. The maternal mortality rate reduced from 651 per 100 000 live births (ZDHS 2015) to 462 deaths per 100,000 live births (MICS 2019). Despite the reduction, the maternal mortality rate is still unacceptably high. Abortion is a major contributor to maternal deaths. Health facility data for 2018 has shown that abortion related maternal deaths account for 25% of all maternal deaths. In 2016, an estimated 65,300 induced abortions occurred in Zimbabwe. This translates to a rate of 17 abortions for every 1,000 women aged 15–49. Of these abortion cases, only 25,200 (39%) received facility-based post abortion care. Due to Zimbabwe’s restrictive abortion laws, abortion is highly restricted and permitted only in cases of rape, incest and when the baby’s and/or mother’s life is at risk. Because of this, little is known about the real status of post-abortion care services in Zimbabwe.

Post abortion care (PAC) services in health facilities are an important intervention to reduce abortion related maternal deaths. UNAIDS, UNICEF, UNFPA, and WHO, under 2gether4SRH Programme supported the Ministry of Health and Child Care to establish the status of provision of post abortion care in the 12 districts implementing the programme. 2gether 4SRH is a regional programme for “Strengthening integrated SRHR/HIV and SGBV services in East and Southern Africa to accelerate action on SDG 3 and 5”.

The assessment focused on the availability of post abortion care services in the health facilities, health care workers’ skills on provision of PAC services and availability of equipment, instruments, commodities/supplies and medicines required for management of abortion cases. A cross sectional study among health care workers from the 12 districts was conducted. 12 district hospitals and their six (6) referral hospitals were assessed. Semi-structured questionnaires, the health facility assessment and the skills assessment tool were used to gather data from the sampled health facilities. Face to face interviews with key informants from out-patients’ department, general female ward, maternity, human resources, pharmacy, laboratory, and health information departments were conducted. Direct observations on the status of infrastructure, equipment, furniture, medicines and other consumables were also done.

The assessment revealed that all 18 health facilities assessed were providing treatment services to women with abortion. Manual Vacuum Aspiration (MVA), Dilation and curettage (D&C), medical abortion and Electric Vacuum Aspiration (EVA) were the most prominent procedures used to treat women with abortion complications, and the most common procedure performed by doctors was the dilatation and curettage.

The assessment also revealed that all health care workers trained on post abortion care had skills on performing manual vacuum aspiration procedures. However, notwithstanding the good performance, most health care workers 79% (11/14) were not giving bereavement counselling to their clients. Although there were health care workers trained on post abortion care, they were inadequate. A massive exodus of health workers trained on post abortion care was reported. This was also worsened by the limited coverage of post abortion care courses in pre-service medical and midwifery education programs in Zimbabwe. Pre-service medical education in Zimbabwe does not include manual vacuum aspiration training, and this may explain why doctors prefer performing Dilatation &curettage as compared to manual vacuum aspirations.

The assessment also revealed that the designated 2gether for 4SRH facilities had inadequate supplies, instruments and equipment needed for post abortion care. For instance, 83% (15/18) of the facilities had no sterile water, 78% (14/18) had no strainer for tissue inspection, 72% (13/18) had no aspirin, 73% (13/18) had no manual vacuum aspiration kits and 94% (17/18) had no cidex (disinfectant). This limits the capacity of health facilities to deliver post abortion care services. Most of the facilities were improvising the post abortion registers, hence the completeness of data was affected. Only 28% (5/18) health facilities had standard post abortion care registers while close to half (44%) were using the improvised ones. The unavailability of standard post abortion care registers in the facilities pose a threat to the quality of post abortion care data across the facilities. This may also suggest an underestimation of the true -magnitude of the burden of abortion cases.

Based on the above findings, the Ministry of Health and Child Care with support from UNAIDS, UNICEF, UNFPA, and WHO recommended the strengthening of the nursing and medical schools pre-service training in post abortion care through inclusion of all procedures for treating/managing abortions in their curriculum, as a long-term plan. Another recommendation was that health facilities should implement a standard/structured on the job training programme for all health care workers manning all sections that provide post abortion care services. Scaling up in-service training of more health care workers in manual vacuum aspiration was also recommended. The development and implementation of a framework that will increase focus on prevention by strengthening the ‘community and service partnership element in the post abortion care model was also recommended. To improve on quality of post abortion care data, it was recommended that Family Health Department should distribute the standard post abortion care register to all facilities in the country and health care workers should improve on documentation.

Source: World Health Organization. Africa