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Measuring Abortion Incidence, Severity of Complications, and Health Facilities’ Capacity to Provide Abortion Care in Refugee Settings in Uganda, BAOBAB STUDY

Uganda, 2023
Health and Well-Being (HaW)
Yohannes Wado
Last modified October 02, 2025 Page views 12138 Documentation in PDF Metadata DDI/XML JSON

Identification

IDNO
DDI-UGA-APHRC-BAOBAB-2023-v1.0
Title
Measuring Abortion Incidence, Severity of Complications, and Health Facilities’ Capacity to Provide Abortion Care in Refugee Settings in Uganda, BAOBAB STUDY
Subtitle
BAOBAB STUDY
Country
Name Country code
Uganda UG
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 Uganda.
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 provide the data 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
2025-07-30
Version Notes
N/A

Coverage

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

Individual - PAC patients, Knowlegeble Informants
Institutional (Health Facility) - PAC is providers
Universe
The components of the survey covered refugee settlements in Uganda, women aged 15-49 residents of the setttlement, health facilities located within or just outside the refugee settlements and individuals who were knowledgeable about induced abortion among refugee populations.

Producers and sponsors

Authoring entity/Primary investigators
Agency Name Affiliation
Yohannes Wado African Population and Health Research Center (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
Stephen Kizito Population Council Kenya Co-investigator
Francis Obare Population Council Kenya Co-investigator
Chi-Chi Undie Population Council Inc Co-investigator
Stella Muthuri Population Council Inc Co-investigator
Gloria Seruwagi Population Council Inc Co-investigator
Dagim Habteyesus Population Council Inc Co-investigator
Caitlin Rich Guttmacher Institute Co-investigator
Bonnie Wandera African Population and Health Research Center Co-investigator
Yadeta Dessie Bacha African Population and Health Research Center 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
Office of the Prime Minister Government of Uganda
Department of Refugees Government of Uganda
Ministry of Health Government of Uganda
District Health Officers Government of Uganda
United Nations High Commissioner for Refugees (UNHCR) Uganda
Janet Munyasya Boabab RPC administrative support
Bonface Ingumba African Population and Health Research Center Data Governance Officer

Sampling

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

It was administered to all health facilities located within the 13 refugee settlements in Uganda. However, due to the integration of social services, including healthcare, some women from the host community had accessed services (or even reside) within the refugee settlements, and refugee women could choose to visit health facilities located outside the settlements. Therefore, we did not limit the HFS to facilities located within the 13 refugee settlements in Uganda. To construct the census, UNHCR provided a list of facilities (n=110) capable of providing PAC located within or just outside all 13 refugee settlements that were in operation at the time of data collection. However, upon further investigation, we excluded 17 of these facilities, either because they had health posts that do not provide PAC (n=8), do not serve refugees (n=3), or because they had recently closed (n=6). In addition, we identified additional eligible facilities during the fielding process that were not included in the UNHCR list (n=9). As such, our final HFS sample consisted of 102 facilities. At each facility, a senior staff member who was knowledgeable about the provision of PAC and had been working at their facility for at least 6 months was interviewed. Facility types included Health Center II (typically small health clinics), Health Center III (larger health centers with maternity wards), and Health Center IV and above (hospitals with maternity wards and inpatient services). Overall, 89.2% of facilities (n=91) were located within the borders of a refugee settlement.

Knowledgeable Informant Survey
For the KIS, we purposely identified and sampled individuals who were knowledgeable about induced abortion among refugee populations in Uganda. These individuals included providers who serve refugee women, including nurses, midwives, clinical officers, doctors, social workers, traditional birth attendants, and community health providers, as well as district-level health officers and coordinators and staff at NGOs that provide services to refugee women within the settlements. The final sample consisted of 59 of these knowledgeable informants.

Prospective Morbidity Survey
To select facilities for the PMS, we asked HFS Research Assistants to collect contact information of facility leadership for potential PMS participation. We contacted and invited all facilities to participate in the PMS. We excluded Health Posts (HPs) from the sample, which typically do not provide PAC. However, given that facility levels can often change, there were some discrepancy between levels identified in our original HFS universe, and the level the facility was later identified as when in the field. For example, despite excluding HPs from our sampling frame, one HP was included as it was erroneously classified as a level 3 facility in our HFS sample and was dropped from analysis. In addition, some facilities were unable to send health facility staff to the PMS training. As such, the final PMS sample consisted of 65 health facilities.
Deviations from the Sample Design
PMS: A sample was randomly drawn from the original list of facilities provided to us by UNHCR Uganda. The original sampling design was based on facility level, drawing 0% of HPs, 40% of HC IIs, and all HC IIIs and HC IVs. Some facilities in the UNHCR master list were found in the HFS to not provide PAC, and were purposively replaced by facilities that did provide PAC. One HP was mistakenly included in PMS fielding, but was dropped from analysis.

KIS: N/A

HFS: N/A
Response Rate
KIS: N/A

HFS: 100% (census survey)

PMS, Uganda: Of the 78 facilities sampled for participation in the PMS, a total of 65 participated (response rate: 67.9%). Due to the sampling deviation described above (the PMS sample being drawn from the original UNHCR facility list during HFS fielding), 15 facilities were purposively replaced by those deemed to be ineligible due to non-provision of PAC. 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 89% overall, 85.7% at HC IIs, 88.6% at HC IIIs, and 94.9% at HC IVs.
Weighting
HFS & KIS: N/A

PMS: The variable named, wgt_pmsind, was used as the weighting coefficient. This weight was a product of two calculations:
-stage1 was the total number of PAC patients presenting to 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 to sample facilities during PMS fielding by facility level.

Data Collection

Dates of Data Collection (YYYY/MM/DD)
Start date End date
2023-03-01 2023-05-31
Mode of data collection
Face-to-face [f2f]
Supervision
Field teams for the HFS and KIS were organized into two groups: north and south. Each group had seven RAs, managed by one study coordinator. The PMS exercise which consisted of 65 health facilities was supervised by six study coordinators. All coordinators were supervised by the in-country PI. The roles of coordinators included the following:
1) Provide logistics support during training of field teams.
2) Provide logistics support for research staff and data collection teams during fieldwork and ensure the smooth and efficient day-to-day operation of research and data collection activities.
3) Monitor progress of research activities, develop and maintain records of research activities, and prepare periodic and ad hoc reports on fieldwork progress, as required by study investigators, administrators, funding agencies, and/or regulatory bodies.
4) Implement quality control procedures throughout the data collection period.
5) Maintain an inventory of Tablets for data collection.
6) Coordinate fieldwork activities, including introducing the study to relevant stakeholders
7) Read and understand the protocol for the data collection process to facilitate the execution of the expected tasks.
8) Participate in in-person training to understand the study objective, design, research ethics and the process of data collection.
9) In collaboration with the Research Assistants, list professionals who are well-informed about abortion provision and post-abortion care in the public and private/NGO sectors in refugee settings in Uganda
10) Book an appointment for Knowledgeable Informant Survey (KIS) participants and Health Facility in-charges
11) Visit assigned study sites to support conducting KIS and HFS using relevant survey tools
12) Support research assistants to generate a summary of the data outputs and transmit the same daily
13) Maintaining regular communication between Research Assistants, Principal Investigator (PI) and co-investigators (co-I) of the project
14) Compile the summary fieldwork reports
15) Participation in a de-brief meeting
16) Perform miscellaneous job-related duties as assigned by the study investigators.
The in-country PI visited the field on a weekly basis to provide leadership, oversight, technical guidance, troubleshooting and ensure that the field teams are following the protocol during implementation. The in-country PI was also a link between the field teams and upper management through providing weekly updates of what is happening in the field but also relaying information to the field teams in terms of what needs to be improved, changed or corrected.
Type of Research Instrument
The study used four questionnaires during data collection with different target population. The questionnaires were written 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 provided data necessary 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.

3. Respondent Identifiers: The Center is committed to protecting the identity of the respondents who provide information in its research. All analytical data sets (both qualitative and quantitative) released by the Data Unit MUST be anonymized by removing the respondent identifiers to protect the identity of the respondents. By accepting to use APHRC data, the user is pledging that he/she will not, under any circumstance, regenerate the identifiers or permit others to use the data to learn the identity of any individual, household or community included in any data set.

4. Confidentiality pledge: The user will not use nor permit others to use the data to report any information in the data sets that could identify, directly or by inference, individuals or households.

5. Reporting of errors or inconsistencies: The user will promptly notify the Head of the Statistics and Survey Unit any errors discovered in the data as soon as the errors are discovered.

6. Publications resulting from APHRC data: The Center requires external collaborators to work with APHRC staff on all publications resulting from its data. In order to facilitate this, lead authors should send a detailed concept note of the paper (including the background, rationale, data, analytical methods, and preliminary findings) to the Principle Investigator (or Theme Leader) for the project (with a copy to the Director of Research), who will circulate the abstract to concerned researchers for possible expression of interest in participating in the publication as co-authors. Any exception to the involvement of APHRC staff should be approved by the Director of Research, APHRC.

7. Security: The user will take responsibility for the security of the data by ensuring that the data are used and stored in a secure environment where access is password protected. This will ensure that non-authorized people do not have access to the data.

8. Loss of privilege to use data: In the event that APHRC determines that the data user is in violation of the conditions for using the data, or if the user wishes to cancel this agreement, the user will destroy the data files provided to him/her. APHRC retains the right to revoke this agreement or inform publishers to withhold publication of any work based wholly or in part on its data if the conditions for using the data are violated.

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."

10. Deposit of Reports/Papers: The user should submit electronic and paper copies of all publications generated using APHRC data to the Policy Engagement and Communications Department, with copies to the Director of Research.

11. Change of contact details: The user will promptly inform the Director of Research of any change in your personal details as contained on this data request form.
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-UGA-APHRC-BAOBAB-2023-v1.0
Producers
Name Abbreviation Role
African Population and Health Research Center APHRC Documentation of the DDI
Date of Production
2025-07-30
Document version
Version 1.0(JULY 2025)