Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis
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RESEARCH
Health system capacity for post‑abortion care in Java, Indonesia: a signal functions analysis Jesse Philbin1* , Nugroho Soeharno2, Margaret Giorgio1, Rico Kurniawan2, Meghan Ingerick3 and Budi Utomo2
Abstract Background: The quality of obstetric care has been identified as a contributing factor in Indonesia’s persistently high level of maternal mortality, and the country’s restrictive abortion laws merit special attention to the quality of postabortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals. Methods: Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia’s most populous island, we applied a signal functions analysis to measure the health system’s capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures. Results: Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia’s current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C). Conclusions: Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/ Gyns to perform this procedure would greatly improve the capacity of Java’s health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service. Keywords: Post-abortion care, Abortion, Miscarriage, Task-shifting, Health system, Service quality
*Correspondence: [email protected] 1 Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY 10038, USA Full list of author information is available at the end of the article
Plain English summary Post-abortion care (PAC) prevents complications resulting from unsafe abortions and miscarriages from escalating to more severe health problems or death, and is especially important in countries with restrictive abortion laws, such as In
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