Assessing health systems' capacities to provide post-abortion care: insights from seven low- and middle-income countries

Background: Abortion-related complications significantly contribute to maternal morbidity and mortality globally. Post-abortion care (PAC) services are essential to safeguarding women's rights by substantially mitigating the health risks associated with abortions - a step which is fundamental to achieving reproductive and maternal health-related Sustainable Development Goals.

Methods: We conducted a secondary analysis of data from the nationally representative Service Provision Assessment (SPA) surveys conducted between 2015 and 2024 across three regions in seven low- and middle-income countries: Afghanistan, Bangladesh, Nepal, the Democratic Republic of Congo (DRC), Ethiopia, Senegal, and Haiti. We included 2951 primary facilities and 473 referral facilities offering normal delivery services. We used PAC signal functions to report capacity to provide basic and comprehensive PAC services in primary and referral facilities, respectively.

Results: Of all primary facilities offering normal delivery services, 50% in Afghanistan, 1% in Bangladesh, 8% in Nepal, 5% in DRC, 34% in Ethiopia, 38% in Senegal, and 19% in Haiti had the capacity to provide basic PAC services. Of the referral facilities, 47% in Afghanistan, 16% in Bangladesh, 50% in Nepal, 52% in DRC, 75% in Ethiopia, 46% in Senegal, and 32% in Haiti had the capacity to provide comprehensive PAC services. Primary facilities in Bangladesh, DRC, and Nepal had critical gaps in referral, ie, effective communication with referral centres and availability of a functional vehicle for emergency transportation. In referral facilities, 74% in Bangladesh and 59% in Nepal had the provision of blood transfusion. In terms of basic PAC services in primary facilities, the capacity of Senegal (from 16% in 2015 to 38% in 2019; P = 0.001) and Haiti (from 12% in 2013 to 19% in 2018; P = 0.007) increased, but the capacity of Bangladesh decreased (from 4% in 2014 to 1% in 2017; P = 0.016) over time.

Conclusions: There are substantial gaps in the capacity to provide basic and comprehensive PAC services in the selected countries. Investing in primary healthcare and improving communication and transportation should be the priority for enhancing basic PAC services, while strengthening referral hospitals to effectively handle emergencies and conduct major surgeries could significantly bolster their capacity to provide comprehensive PAC services.