The Epidemiology of Unsafe Abortions in Kenya, Abortion Incidence and Complication from Unsafe abortions in Kenya
Abortion Incidence and Complication from Unsafe abortions in Kenya
Globally, unsafe abortion is recognized as a major public health issue. Unsafe abortion is a major problem in developing countries for women in their reproductive years. In the past decade, more than 500,000 women have died from complications of unsafe abortion. In Kenya, as in many other societies research shows that unsafe abortion is a major cause of maternal morbidity and mortality. Each year in Kenya, over 3,000 women die of complications of unsafe abortion and another half a million more suffer short and long term morbidities. Improved access to high-quality comprehensive abortion care, will not only save lives but can reduce costs to health systems and facilities. According to the last study conducted in Kenya the bulk of post-abortion care and services were offered at public secondary and tertiary level health facilities. To effectively develop and deliver programs and interventions that will address existing gaps in the delivery of comprehensive abortion care services and promote more effective legislation on abortion, up-to-date empirical evidence on the magnitude of unsafe abortions and incidence of induced abortions in Kenya is urgently needed. This study was conducted in 2012 among a nationally-representative sample of Levels II to VI public and private health facilities. The Abortion Incidence Complications Methodology (AICM) and the Prospective Morbidity Methodology (PMM) were used as well-established and complementary approaches to estimate abortion incidence and the severity of unsafe abortion complications in Kenya.
Version 1.2, November 2014. Anonymized with DOI and Recommended Citation added.
Unit of Analysis
Health Facility Survey- Health facility
Prospective Morbidity Survey- A Post abortion or Abortion service client
Health Professional Survey- Individual Health Professional (Medical and non-medical)
Health Facility Survey- Targeted a nationally representative sample of all public and private sector facilities in Kenya
Prospective Morbidity Survey- Targeted recruiting and interviewing all women who sought abortion or post abortion care services in all selected facilities over a period of 30 days of observation
Health Professional Survey- Targeted to interview health professionals (medical and non-medical) in Kenya
Producers and sponsors
Authoring entity/Primary investigators
African Population and Health Research Center
Dr Susheela Singh
Dr Brooke Levandowski
Dr Chimaraoke Izugbara
African Population and Health Research Center
Consortium for Research on Unsafe Abortions in Africa
UK Department for International Development
Government of the Netherlands
The Maternal and Reproductive Healh Unit
Minstry of Health, Kenya
IPAS Africa Alliance
Kenya Medical Association, Kenya Obstetrical and Gynecological Society (KOGS)
Kenya Medical Association
Kenya Medical Association
Population Studies and Research Institute
University of Nairobi
The Kenya Essential Package for Health (KEPH) defines six levels of preventive and curative public and private health service provision in Kenya (National Coordinating Agency for Population and Development ( NCAPD) [Kenya], 2011 #176) which are listed on the Health Management Information System' (HMIS) Master Facility List. The most recent Master Facility List obtained in January 31, 2012 was used to identify the facilities with the potential to provide PAC services from which the nationally representative sample of facilities was selected for the HFS and PMS, giving a sampling frame of 2,838 health facilities. A stratified random sampling approach was used to select the health facilities to be surveyed. The health facilities were stratified by region and level or type of facility. All facilities from level V and VI were included in the sample; because these facilities are most likely to manage and treat high numbers of abortion-related complications in Kenya. Level II-IV facilities' sampling fractions varied as follows depending on the region: Level IV health facilities were sampled at 18% to 36%; Level III health facilities at 8% to 15%; while Level II facilities were represented at 5% to 19%. The total number of facilities selected was 350. Of the 350 sampled health facilities, complete questionnaires were obtained from 328 health facilities for the HFS and 326 facilities for the PMS. Public facilities had a response rate of 99% while the private for-profit and private not-for-profit had a response rate of 92% and 80%, respectively. Of the 6% of the facilities that did not participate, reasons for non-response included an unwillingness by facility officials to participate in the study (5%) and inaccessibility of the facility to interviewers due to political insecurity (1%).
A puposive sample of health professionals was selected with special consideration of geographical representation with respect to their current official place of work.
A total of 328 facilities responded to the Health Facility Survey, representing a Survey response rate of 92.7%.
Sampling weights are used for both the health facility survey and the Prospective Morbidity Survey data sets. This was based on the inverse of the probability of a facility being selected from the frame. In both the HFS and PMS data, the weighting variable is named "wt". The HPS data is not weighted since sampling was purposive.
Dates of Data Collection (YYYY/MM/DD)
Time periods (YYYY/MM/DD)
Mode of data collection
All research team led by the Principal Investigator, were involved in day-to-day activities of the project. This included training, coordinating field activities and retraining field workers as well as conducting the key informant interviews with senior staff at the ministry of health (Then ministry of medical services and ministry of public health and sanitation).
The field teams was further organized into teams all headed by field supervisor. The field supervisor was in charge of ensuring all field data quality measures were implemented by all field data team members including 5% call backs and 100% checks on all questionnaires. They would also ensure a seamless transmission of completed questionnaires to the office for data entry and archiving.
Type of Research Instrument
Health Facility Survey (HFS) , Prospective Morbidity Survey (PMS) and the Health Professionals' Survey (HPS) tools
The HFS was conducted with a senior health professional knowledgeable about post-abortion care provided at the facility. At large facilities, such as hospitals, the respondent was the chief of the obstetrics and gynecology department, or an obstetrician-gynecologist. At lower level facilities, a nurse, midwife or another health worker in a position to provide information about abortion care in that facility was interviewed. Each respondent completed a face-to-face interview, using a structured questionnaire. Retrospective estimates of the number of in- and out-patient PAC cases treated at that facility in the past month and typical month, or if that was not possible for the respondent to estimate, then a retrospective estimate of the number of in- and out-patient PAC cases treated at that facility in past year and typical year were obtained from HFS respondents. Other information collected included the characteristics of the health facility, facilities' PAC practice and post-abortion counseling. Data collectors for the HFS were trained on the study's methodology and the questionnaire.
The PMS captured data on services received by each woman who came into the health facilities during a 30 day period for post abortion care. Data collected by the PAC providers included patients' demographics, diagnosis on admission, types of treatment received and outcome of the treatment. Data collectors for the PMS were PAC providers at the same sample of health facilities. They were trained in the study methodology and PMS questionnaire. In facilities with a high volume of patients, two PAC providers were trained on the questionnaire. The trained PMS data collectors in low volume facilities were also expected to train colleagues at their facilities to assist in data collection especially when not on duty. Fieldwork was conducted between April and May 2012 for both the HFS and PMS.
The research team, along with input from the project's Advisory Panel, generated a list of key informants who are knowledgeable about the provision of abortion and post-abortion care in different regions of Kenya. Selected respondents included researchers, obstetrician/gynecologists, nurses, midwives, lawyers, clinical officers [mid-level medical providers], politicians, and activists. Topics covered in the questionnaire included respondents' perceptions regarding the type of providers' women seek abortions from in Kenya, the likelihood of women experiencing abortion complications that require treatment according to the type of provider performing the abortion and the likelihood that women who need treatment receive it.
All data forms were checked 100% by the field supervisors and 100% by the office editors. In the office where all questionnaires were submitted for data entry, all questionnaires were received by a designated office data editor, whom, working with the archiving staff logged in all data forms. They were also responsible for a further 100% check of all questionnaires to ensure completeness and accuracy. They also would check the questionnaires vs all field control data sheets to ensure that all data collected in the field was actually submitted to the office for capture. Once this is completed, all data questionnaires were passed to the data entry supervisor who would assign data questionnaires to specific data entry staff.
Data entry screens were developed in CSPro. Extensive controls were implemented to ensure minimal inconsistencies in the final data.
Once all data were entered, there were two more levels of data editing. The database programmer and data manager checked all data, once more for completeness. Outright inconsistencies were also corrected at this stage before data was exported to Stata for further cleaning and eventually analysis.
All data was captured using paper questionnaires. Once these questionnaires were submitted to the office, the data were captured in CSPro and finally exported to Stata for analysis
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African Population and Health Research Center, The Epidemiology of Unsafe Abortions in Kenya, September 2013. APHRC, Nairobi - Kenya. doi:10.20369/aphrc-005:2012.1.01
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