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Measuring Abortion Incidence, Severity of Complications, and Health Facilities’ Capacity to Provide Abortion Care in Refugee Settings in Ethiopia, Baobab Study

Ethiopia, , 2024
Health and Well-Being (HaW)
Yohannes Wado
Last modified October 02, 2025 Page views 20978 Documentation in PDF Metadata DDI/XML JSON

Identification

IDNO
DDI-ETH-APHRC-BAOBAB-2023-v1.0
Title
Measuring Abortion Incidence, Severity of Complications, and Health Facilities’ Capacity to Provide Abortion Care in Refugee Settings in Ethiopia, Baobab Study
Subtitle
Baobab Study
Country
Name Country code
Ethiopia ETH
Abstract
Abstract
Background: Sparse evidence is available to support improved programming and reporting on SRHR in refugee settings in the east and horn of Africa, where unsafe abortion is one of the major causes of maternal mortality and morbidity. It is important to design studies that explicitly investigate the sexual and reproductive health needs and outcomes of refugee populations, as it is likely that these factors differ among refugee populations as opposed to the general population. Understanding the state of abortion in a given context, including abortion incidence, safety, and outcomes, is challenging due to the limitations of currently available methodologies.
Objectives: To determine the incidence of induced abortions and the severity of abortion-related complications in refugee settings in Ethiopia.
Methods: The study employed a quantitative cross-sectional design. The study components included three separate surveys though the study was not nationally representative, but efforts were made to ensure representativeness at the refugee settlement/camp level : i) representative Health Facility Survey (HFS) to estimate the number of women who receive post-abortion care (PAC) following abortion complications, ii) a Knowledgeable Informants Survey (KIS) to captured information on the proportion of all women having abortions who receive facility-based treatment for abortion-related complications, and iv) a Prospective Morbidity Survey (PMS) to capture information necessary to describe characteristics of women receiving treatment for abortion complications, the severity of complications, the type of treatment received, and the delays in access to PAC. The PMS also included clinical data abstraction from the medical records.
Potential Impact: This will help host governments, humanitarian partners, and donors to seek long-term, innovative, cost-effective SRHR development solutions to bring about change in the health and lives of refugee women and girls.

Version

Version Date
2025-08-04
Version Notes
N/A

Coverage

Geographic Coverage
Refugee settings in Ethiopia
Unit of Analysis
Abortion Incidence, Severity of Complications, and Health Facilities' Capacity to offer Post Abortion Care for people living in refugee settings in Ethiopia.

Individual - PAC patients, Knowlegeble Informants
Institutional (Health Facility) - PAC is providers
Universe
The study targeted women living in refugee setting with; Health Facility Survey (HFS) targeting health facilities in the refugee setting and the surrounding, Knowledgeable Informants Survey (KIS) collected information on the proportion of all women having abortions who receive facility-based treatment for abortion-related complications, and Prospective Morbidity Survey (PMS) captured information to describe characteristics of women receiving treatment for abortion complications, the severity of complications, the type of treatment received, and the delays in access to PAC. The PMS also included clinical data abstraction from the medical records.

Producers and sponsors

Authoring entity/Primary investigators
Agency Name Affiliation
Yohannes Wado APHRC
Producers
Name Affiliation Role
Caroline Kabiru African Population and Health Research Center Co-investigator
Margaret Giorgio Guttmacher Institute Co-investigator
George Odwe Population Council Kenya Research Associate
Stephanie Kung Guttmacher Institute Research Associate
Peter Kisaakyee Population Council Kenya Research Fellow
Hellen Akinyi African Population and Health Research Center Data documentarist
Yadeta Dessie Bacha African Population and Health Research Center Co-investigator
Bonnie Wandera African Population and Health Research Center Co-investigator
Francis Obare Population Council, Kenya Co-investigator
Stephen Kizito Population Council, Kenya Co-investigator
Dagim Habteyesus Population Council - Ethiopia Office Co-investigator
Stella Muthuri Population Council - Ethiopia Office Co-investigator
Chi-Chi Undie Population Council, Inc. Co-investigator
Gloria Seruwagi Population Council, Inc. Co-investigator
Caitlin Rich Guttmacher Institute Co-investigator
Funding Agency/Sponsor
Name Abbreviation Role
Foreign, Commonwealth & Development Office FCDO Funder
Norwegian Agency for Development Cooperation NORAD Funder
Other Identifications/Acknowledgments
Name Affiliation Role
Bonface Ingumba African Population and Health Research Center Data Governance Officer
RRS and regional Health Bureaus Ethiopia

Sampling

Sampling Procedure
Sampling took place at different levels of the study since it had different components:
Health Facility Survey

Our sampling universe for the HFS included all facilities that theoretically offer post-abortion care (PAC) services to refugee women. In Ethiopia, the facility levels are hospitals (public and private), health centers, and higher level/NGO private clinics. In Uganda, these levels are Health Center IIs and above. Our sampling universe included all facilities located within the geographical boundaries of each camp. However, in some instances women chose to seek care outside of the camp boundaries, either because those facilities are more geographically convenient to access or because women wanted greater privacy when seeking postabortion care. As such, we worked with key informants to identify additional facilities outside of the camp boundaries that served refugee women.

Within selected facilities, respondents are the most qualified to answer questions about PAC caseloads and the types of cases seen at the facility. Depending on the facility they were senior administrators, heads of the OBGYN ward, or heads of private clinics, including medical doctors, nurses and midwives.
Knowledgeable Informant Survey

The study population of the KIS was professionals who were knowledgeable about the conditions of abortion and the provision of post-abortion care among refugee women in Ethiopia and Uganda. These included medical doctors, registered nurses and midwives in public and private practice, policymakers, advocates, researchers, NGO staff, community health workers, and community leaders. Interviews were carried out at the respondents' place of work or setting of the respondents' choice.

A purposive list of potential respondents working in refugee settings in Ethiopia was drawn up by the research team, and the final selection was reviewed and approved by the study team. Respondents who were invited to participate but said they were not familiar enough with this subject to inform the study, or refused to grant an interview, were excluded.

Prospective Morbidity Survey

We selected a subset of health facilities that were sampled for the HFS to be included in PMS. Once our sample of PMS facilities was selected, we attempted to survey all women who received PAC at that facility over a 28-day period. In addition, the data collectors accessed the medical charts of the PAC patients to extract data related to reported diagnosis, laboratory measurements and management procedures undertaken.

While this study is focused on refugee women, we did not restrict participation to only refugee women seeking care. Instead, we assessed whether a patient was a member of the host community or a refugee. This allowed our study to compare severity outcomes based on refugee status. In addition, this provided additional information on the distribution of patients served within our sample of health facilities.

In accordance with previous AICM studies, we also identified one staff member at each sampled health facility to keep a real-time tally of the number of women who sought PAC over the 28-day period. This allowed the study team to adjust for non-response to the PMS survey, and this data also provided an important validation of the PAC caseload estimates that we generated from the HFS.
Deviations from the Sample Design
HFS: Facilities in two of the 24 refugee camps in Ethiopia were excluded from the survey: one camp in Amhara region due to security challenges, and one camp in Afar region which had closed.

PMS: The PMS sampling frame was drawn from the HFS sample and was informed by PAC provision, caseloads, and the proportion of refugees served. From the HFS facilities, the PMS sampling plan was to
include:
- All hospitals and MCH clinics;
- All facilities that participated in the HFS and served at least 10 PAC patients per month; and All facilities located within refugee camps that provided PAC.
- Facilities located outside of refugee camps that provided PAC were included at the discretion of study partners in Ethiopia.
The was to exclude Facilities that had low caseload of PAC patients , located outside of refugee camps and served less than 6% of refugees were excluded. We deviated from this original plan mainly on the point of excluding facilities with a low caseload of PAC patients that were outside of the camp, as some of these facilities were included. These decisions were made at the discretion of study partners in Ethiopia.
Response Rate
PMS: Of the 66 facilities sampled for participation in the PMS, a total of 47 participated (response rate: 71.2%). Regarding the individual-level response rate, all patients treated at the sampled facilities during
the study period were eligible to participate in the study. The participation rate of patients was 84.2% overall, 76.8% at health centers, 100% at private clinics, and 84.4% at hospitals.
Weighting
PMS : The variable named, wgt_pmsind, was used as the weighting coefficient. This weight was a product of two calculations:
- stage 1 was the total number of PAC patients presenting at sampled facilities during PMS fielding divided by the number of patients that participated in the PMS. This was meant to account for individual-level response rates.
- stage2 was another division meant to account for the total universe of PAC cases (including PAC cases served at facilities not sampled in the PMS). The numerator was the total number of PAC patients estimated to be treated by facility level, which was calculated using questions from the HFS on PAC patients seen during the past month and an average month at each facility. The denominator was the total number of PAC patients presenting at sample facilities during PMS fielding by facility level.

Data Collection

Dates of Data Collection (YYYY/MM/DD)
Start date End date
2024-02-01 2024-05-30
Mode of data collection
Other [oth]
Supervision
The Baobab team and the Guttmacher team coordinated and supervised the KIS/HFS and PMS. One co-principal investigator and a co-investigator, based in Ethiopia, closely monitored the daily data collection activities. Meanwhile, the central team provided overall leadership and coordination. A total of 11 data collectors and one coordinator participated in KIS/HFS data collection across five regions: Gambella, Asosa, Semara, Jigjiga, and Melakdida. For the PMS, 49 data collectors and six coordinators were involved. These interviewers worked closely with his or her supervisors, the study coordinators, Baobab RPC and Population Council Ethiopia technical staff, and other project partners.
Type of Research Instrument
The study used four questionnaires during data collection at different data points with different target population. The questionnaires were in english. The HFS questionnaire captured information to estimate the number of women receiving treatment in facilities for complications from unsafe abortions, the KIS questionnaire was used to collect information on the proportion of all refugee women having abortions who received facility-based treatment for abortion-related complications and the PMS captured information to describe characteristics of women living in refugee settings and receiving treatment for abortion complications, the type of treatment received for complications, uptake of post-abortion family planning, and the delays in access to post-abortion care. The PMS also included charts review to abstract data on laboratory measurements, procedures and management of complications for PAC patients.

Data Processing

Cleaning Operations
Interviews for all surveys was conducted face-to-face, using Open Data Kit (ODK) software on Android smartphones. Completed ODK forms were submitted to a secure cloud server using Wi-Fi or mobile data networks accessible only to the study team. The data was later uploaded to Stata to be cleaned and analyzed.
Other Processing
N/A

Data Appraisal

Estimates of Sampling Error
Analyses were performed in Stata 19. The dataset was weighted using the following command: svyset [pweight=wgt_pmsind].

Data access

Contact
Name Affiliation Email
African Population and Heath Research Center APHRC datarequest@aphrc.org
Conditions
All non-APHRC staff seeking to use data generated at the Center must obtain written approval to use the data from the Director of Research. This form is developed to assess applications for data use and facilitate responsible sharing of data with external partners/collaborators/researchers. By entering into this agreement, the undersigned agrees to use these data only for the purpose for which they were obtained and to abide by the conditions outlined below:

1. Data Ownership: The data remain the property of APHRC; any unauthorized reproduction and sharing of the data is strictly prohibited. The user will, therefore, not release nor permit others to use or release the data to any other person without the written authorization from the Center.

2. Purpose: The provided data must be used for the purpose specified in the Data Request Form; any other use not specified in the form must receive additional or separate authorization.

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9. Acknowledgement: Any work/reports from this data must acknowledge APHRC as the source of these data. For example, the acknowledgement for our data is:

"This research utilizes data collected through the "Filling Gaps in Evidence to Enhance Sexual and Reproductive Health and Rights Among Vulnerable Populations in the East and Horn of Africa (Baobab)" program. The Baobab Research Program Consortium was funded by the Foreign, Commonwealth & Development Office (FCDO) and implemented by the Population Council Inc., Population Council Kenya, and the African Population and Health Research Center.
We gratefully acknowledge all study participants, health workers, health facility leadership, refugee settlement commandants, and field research assistants for their dedication in supporting and facilitating the data collection process. We also extend our gratitude to the UNHCR Regional Bureau for the East, Horn of Africa, and Great Lakes Region, UNHCR Uganda and its implementing partners, and the Government of Uganda through the Department of Refugees in the Office of the Prime Minister, as well as the Reproductive and Infant Health Department, Ministry of Health, for their invaluable technical support."

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Citation requirement
Use of the dataset must be acknowledged using a citation which would include:
- the Identification of the Primary Investigator
- the title of the survey (including country, acronym and year of implementation)
- the survey reference number
- the source and date of download

Metadata production

Document ID
DDI-ETH-APHRC-BAOBAB-2023-v1.0
Producers
Name Abbreviation Role
African Population and Health Research Center APHRC Documentation of the DDI
Date of Production
2025-08-04
Document version
Version 1.0(AUGUST 2025)