Characteristics of clients and abortion care received
A total of 7,007 women (95%) were successfully followed after their uterine evacuation procedure. There were no statistical differences for sociodemographic characteristics when comparing clients that were and were not successfully followed over time, except for rural or urban residence. Nearly 80% of urban clients were followed successfully, as compared to only 69% of rural clients (p < 0.001).
The distribution of the 7,007 successfully followed patients by facility type is shown in Table . Though only half of CAC sites were NGO facilities, 83% of patients were seen in these facilities. One third of the sampled facilities were government sites, but only 12.8% of patients were seen in government facilities. Private facilities accounted for 11% of the sampled sites but only 3.8% of patients. Most (62.7%) of the CAC clients were from the Central Development Region, the most populated region of Nepal and the location of Kathmandu valley (Table ).
Distribution of 7,007 CAC patients by facility type and region, Nepal 2008
CAC patient sociodemographic information is described in Table . Most women were married (96.0%), lived in rural areas (57.0%), had less than secondary level education (68.6%) and were literate (74.4%). Significant differences were seen in marital status across facility types; less than 80% of private facility patients were married compared to over 96% of government and NGO facility patients (p < 0.05) (Table ). In addition, there were significantly higher proportion of NGO patients were from rural areas (61.4%) compared to less than 40% of patients at government and private facilities (p < 0.05) (Table ). Education was also significantly different by facility type; government and NGO facilities had a less educated patient population than private facilities where only 10.6% of patients had no education (p < 0.05) (Table ). Patients of private facilities were also significantly more likely to be literate compared to patients of government and NGO facilities (p < 0.05) (Table ). The mean patient age was 27 years (sd = 5.8, range: 14-50), and the mean gravidity and parity were 3.2 (sd = 1.63) and 1.8 (sd = 1.36), respectively. Patients at private facilities were younger (mean = 26, sd = 6.28) and had lower gravidity and parity compared to patients at government and NGO facilities (Table ). According to the national CAC protocol, providers verified gestational age before performing the abortion procedure using last menstrual period (LMP) and clinical examination; only 25 women received an ultrasound. The mean pregnancy duration was 7.1 weeks (sd = 1.64) based on LMP and 7.4 weeks (sd = 1.75) based on clinical exam.
Sociodemographic and uterine evacuation procedure characteristics of 7,007 CAC patients, Nepal 2008
All 7,007 patients received first trimester CAC services using MVA. Almost all patients (99%) received some type of pain management (paracervical block with 1% xylocaine and/or oral analgesics), and cervical priming was conducted for 1% of clients (results not shown). Infection prevention practices varied by facility type. Only 63% of government facilities and 67% of private facilities had adequate equipment for infection control, including a heat source for high-level disinfection of instruments and supplies such as antiseptic solution and detergent powder, compared to 92% of NGO facilities (results not shown). Government and private facilities administered antibiotics prophylactically to over 90% of patients, while only 72% of patients at NGO facilities received antibiotics (p < 0.05) (Table ). The mean length of stay from procedure to discharge among all CAC clients was 26 min (sd = 20.4) and ranged from 17 min in government facilities to 42 min in private facilities (results not shown). More than 99% of clients received contraceptive counselling (results not shown), and 81% left with a family planning method (Table ). Among women who accepted family planning, the most popular methods included condoms (38.8%), Depo Provera (20.9%) and oral contraceptives (14.8%) (Table ). Provision of family planning methods differed by facility type; while nearly one-fifth of women left NGO facilities without a method, only 15% of women at government facilities and 5% of women at private facilities left without a method (Table ).
Among the 7,386 patients receiving care at participating CAC centers, 17 experienced signs and symptoms indicative of complications during or immediately after the induced abortion procedure. This resulted in a complication rate of 0.23 per 100 patients (95% CI: 0.05-0.41) at the time of the procedure. The rates varied by facility type (p < 0.05); government facilities reported a complication rate of 0.42 per 100 patients (95% CI: 0.03-0.80) while NGOs reported a complication rate of 0.21 per 100 patients (95% CI: 0.005-0.42). Private facilities did not report any complications during CAC procedures.
Additionally, 131 women experienced signs and symptoms of complications during the follow-up period, yielding a complication rate of 1.87 per 100 women (95% CI: 0.51-3.23). The number and percentage of patients reporting each type of complication are listed in Table for the overall sample and by facility type. The most frequently reported post-procedural complications included retained products of conception (RPOC) (1.37%), offensive discharge (< 1%), moderate bleeding (< 1%) and suspected sepsis (< 1%) (Table ). There were no reported cervical tears/lacerations, uterine perforations, or missed ectopic pregnancies. Cases of RPOC were explored in greater detail, and it was found that these cases were clustered in fewer than half of the providers (results not shown). Twelve NGO providers (34%), 24 government providers (41%) and only 1 private provider (10%) had at least one patient with RPOC (results not shown).
Signs and symptoms of complications at time of follow-up among 7,007 CAC clients, overall and by complication type, Nepal 2008
The complication rate and types of complication during follow-up were also compared across facility type (Table ). Patients at government facilities experienced the highest complication rate (5.93 per 100 patients; 95% CI: 4.9-7.0), followed by private facilities (3.03 per 100 patients; 95% CI: -2.0-8.1) and NGO facilities (1.2 per 100 patients; 95% CI: 0.2-2.2) (Table ). Some complication types, such as RPOC, severe bleeding, uterine atony and failed abortion, were significantly more common in government facilities and others, such as offensive discharge, suspected sepsis and fever, were more common in private facilities (p < 0.05) (Table ). The complication rate was also assessed by residence to determine whether the lower rate of follow-up for rural patients affected the complication rate; rural patients had a significantly lower total complication rate (1.55 per 100 women) than urban patients (2.29 per 100 women) (p < 0.05) (results not shown).
In total, 143 of the 7,007 patients with successful follow-up contact had a documented complication either during the procedure, during the follow-up period, or both, for an overall complication rate of 2.0 per 100 procedures (95% CI: 0.63-3.45) (results not shown). Significant differences in overall complication rates are observed by facility type; NGO facilities have a complication rate of 1.4 per 100 procedures (95% CI: 0.3-2.4), compared to 6.0 per 100 procedures (95% CI: 4.9-7.1) in government facilities (p < 0.05) (results not shown). Women receiving care at NGO facilities have one fifth the odds of experiencing a complication compared to those treated at government facilities (unadjusted OR = 0.22; 95% CI: 0.15-0.31) (results not shown). Table presents results from multivariable logistic regression of the association between experience of a complication and demographic and facility characteristics. After adjusting for facility and patient characteristics, women receiving care at NGO facilities had significantly lower odds of experiencing a complication than women receiving abortion care from government facilities (AOR = 0.18; 95% CI: 0.08-0.40) (Table ). In addition, women who presented for CAC services at higher gestational ages had higher odds of experiencing a complication than women who presented at 4-5 weeks gestation (Table ). At 6-7 weeks gestation, women had 3 times higher odds of experiencing a complication (95% CI: 1.02-8.65), and at 10-12 weeks gestation, women had 4 times higher odds of experiencing a complication (95% CI: 1.38-12.82) (Table ).
Abortion-related complications* by select facility and patient characteristics among 7,007 CAC clients, Nepal 2008
Management of abortion complications
All of the 131 clients with signs and symptoms of complications received treatment at the facility where they had their initial abortion procedure. Among the 96 women with reported RPOC, 89 (93%) underwent re-evacuation, and of those women, 11 received oxytocin/methargin and six received IV antibiotics. All six women who received IV antibiotics for treatment of RPOC attended government facilities; women who were treated in NGO and private facilities did not receive IV antibiotic treatment (results not shown). Among the five women with reported atony, four were treated by administration of oxytocin/methargin, according to the complication management protocol (results not shown).
Although antibiotic administration is included in every protocol for management of abortion complications post-procedure, the majority of the clients presenting with complications in this study did not receive antibiotics. Only 36 (27%) of the 131 women with complications received antibiotics-including 5 (29%) of the 17 cases of suspected sepsis and 15 (68%) of the 22 cases of moderate or severe bleeding (results not shown). A higher proportion of women treated in government facilities received antibiotic treatment for complications (37.7%) compared to NGO (20%) and private facilities (25%) (results not shown).