Background: In many developing countries, maternal deaths occur mainly as a result of unsafe abortions, a situation reflecting the inaccessibility of safe abortion services in such countries. In Ethiopia, unsafe abortion accounts for 32% of maternal deaths and almost 60% of gynaecological admissions, and is one of the top ten causes of general hospital admissions. Purpose: The purpose of this study was to assess the views of women about the accessibility of safe abortion services in governmental health centres. Methods: A quantitative cross-sectional descriptive and non-experimental study using structured questionnaires was conducted. 342 women who had received abortion care services in governmental health centres participated. Findings: 46.8% of the participants do not know about the penal code regarding safe abortion care. 52.9% of the participants viewed safe abortion care as inaccessible because there are various and competing factors which make abortion service to be viewed as accessible or inaccessible and these include distance to nearest health centre, the time it takes to receive the service, the cost of the service, and the lack of appropriate skills in the service providers. Conclusion: An improvement in the accessibility of abortion services will prevent deaths resulting from unsafe abortions / Health Studies / M.A. (Public Health)

Background: In many developing countries, maternal deaths occur mainly as a result of unsafe abortions, a situation reflecting the inaccessibility of safe abortion services in such countries. In Ethiopia, unsafe abortion accounts for 32% of maternal deaths and almost 60% of gynaecological admissions, and is one of the top ten causes of general hospital admissions. Purpose: The purpose of this study was to assess the views of women about the accessibility of safe abortion services in governmental health centres. Methods: A quantitative cross-sectional descriptive and non-experimental study using structured questionnaires was conducted. 342 women who had received abortion care services in governmental health centres participated. Findings: 46.8% of the participants do not know about the penal code regarding safe abortion care. 52.9% of the participants viewed safe abortion care as inaccessible because there are various and competing factors which make abortion service to be viewed as accessible or inaccessible and these include distance to nearest health centre, the time it takes to receive the service, the cost of the service, and the lack of appropriate skills in the service providers. Conclusion: An improvement in the accessibility of abortion services will prevent deaths resulting from unsafe abortions / Health Studies / M.A. (Public Health)

L'avortement provoqué sans indication médicale ou juridique dans les pays où il estinterdit comme au Burkina Faso pose à la fois un problème de santé publique et unproblème social. C'est cette double problématique que cette thèse a exploré pourexpliquer les difficultés que rencontre le pays à lutter contre les avortements à risque, etcomprendre les facteurs de l'accroissement de la pratique parmi les jeunes. Uneimmersion dans l'univers de l'avortement (structures sanitaires et vie de femmes etd'hommes ayant fait l'expérience de l'avortement) ainsi que des entretiens avecdifférents acteurs, ont permis de montrer que la manière dont l'avortement est pensé ettraité dans l'espace public burkinabè concourt à créer des obstacles rédhibitoires à saconstitution en problème réel de santé publique et à sa gestion efficiente. Il est conçusocialement comme une déviance et est fortement reprouvé. Les stigmates consécutifs àcette déviance et ses enjeux moraux et symboliques marquent alors de leur sceau leprocessus conduisant à la reconnaissance sociale et politique du problème. Parconséquent, l'avortement est partiellement inscrit à l'agenda des politiques publiques desanté, et les recours et les modalités d'accès aux services d'avortement dans lesstructures sanitaires s'en trouvent fortement influencés. Quant à l'occurrence del'avortement parmi les jeunes, elle a trait aux pratiques des jeunes urbains dans uncontexte marqué par une mutation des modes d'accès au statut d'adulte et une précaritééconomique et statutaire. Ce travail montre que les grossesses qui aboutissent auxavortements sont la conjugaison d'une hétéronomie des jeunes femmes et dedynamiques d'individuation dans leurs « débrouilles » pour devenir adulte et pourréussir dans la ville de Ouagadougou. À ce titre, cette recherche apporte unecontribution aux réflexions dans les champs de l'anthropologie des jeunes et del'anthropologie de la santé. / Induced abortion without medical or legal request in countries where it is prohibitedsuch as Burkina Faso poses both a public health and social problems. It is this doubleproblematic that this thesis explored in order to understand the causes of the difficultiesfacing the country to fight against unsafe abortions, and the factors that increased thispractice among young people. Immersion in abortion universe (health facilities andlives of women and men who have experienced abortion) and interviews with variousactors, have shown that the way abortion is thought and treated in public space combineto create insurmountable obstacles to its constitution as a real public health problem andits efficient management. It is designed as a deviance and it is highly reprobated.Consecutive stigmata due to this deviance and its moral and symbolic issues mark theirseals to the process leading to social and political recognition of the problem. Therefore,abortion is partially on the public health policies agenda, and access to abortion servicesin health structures are accordingly influenced. The occurrence of abortion among youthrefers to practices among “young people” in a context marked by a mutation of the wayof accessing social adulthood status, as well as economic and statutory precariousness.This work shows that pregnancies that lead to abortions are the combination of aheteronomy and individuation impulses within young women in their resourcefulness tobecome adult and succeed socially and economically in the city of Ouagadougou. Thisresearch therefore contributes to studies in the fields of anthropology of the subject andthe anthropology of health.

Department of Advanced Nursing Science / PhDH / Background: Despite measures to curb unwanted pregnancies and to sustain and expand abortion services, a high number of complications and deaths still occur. The failure of these measures is evidenced by the high number of women who are admitted to the public hospitals of KwaZulu-Natal Province with complications from induced abortions. KwaZulu-Natal Department of Health has repositioned Family Planning to a key priority in its health program in order to improve the situation for women. However, in order to improve the situation, it is necessary to understand the underlying causes. This study sought to identify challenges that affect women's access to Post Abortion Care (PAC) services in KwaZulu-Natal Province, South Africa. It also sought to shed light on the challenges faced by those who render PAC services, as well as assess the skills of those workers as observed while they provided PAC services. After conducting the research on challenges related to access and rendering of post abortion care services, the researcher identified a need to develop guidelines for management of unsafe and induced abortion complications, with the aim to improve the life expectancy of women and prevent maternal deaths. Therefore, an outcome of the study was the development of a PAC management guideline. Purpose: The purpose of the study was two-fold: Phase 1: to explore the challenges faced by women when accessing PAC, and the health care workers who render PAC services, and to assess the PAC skills of the health care workers; Phase 2: to use the findings of Phase 1 to develop guidelines for post abortion care management at selected Hospitals of KwaZulu-Natal Province, South Africa. Methods: The design of the study was guided by the Andersen model of Health Care Utilization. The model focuses on the contextual factors - enabling factors, predisposing factors and need factors - that influence the individual's utilization of health care services. Five districts of KwaZulu-Natal Province, South Africa were selected for the study. A convergent parallel mixed method was used to collect and interpret the data. A qualitative study was used to explore perceptions and challenges of women when accessing PAC; this was carried out by means of in-depth interviews with 23 women who accessed PAC services. Five Focus Group Discussions (FGD) were carried out with 50 health care workers to explore the challenges they experienced when managing abortion complications. A quantitative approach was used for direct skills observation of 92 health care workers. Thematic analysis was used to analyse the qualitative data; descriptive statistics were used to analyse the quantitative data. Results: From the in-depth interview data, several main themes were identified. Women who accessed PAC identified a lack of facilities that offered PAC service, distance from the community to the hospital that provided PAC service, lack of transport, shortage of staff, unskilled staff, shortage of equipment, long waiting queues, stigma and discrimination as challenges associated with delay or avoidance of access to post abortion care services. The main themes raised by the health care providers were lack of support from the management, shortage of staff, lack of training, burnout, unavailability of the guidelines or protocols and shortage of equipment. The quality of PAC services was perceived as poor by both the women seeking care and the health care workers. The main concerns raised by the women were lack of respect, lack of privacy, sharing of bed and insufficient time with the health care provider. The results confirmed that guidelines are needed for the management of post abortion care services. The findings from the qualitative and quantitative parts of the study were used by an expert group to develop PAC management guidelines. The development of the guidelines was in accordance with the WHO models, PICOS & GRADES. The guidelines were validated by the group using a close-ended checklist, analysed with simple descriptive statistics. Conclusion: This study concludes that access to comprehensive quality post abortion care must be provided for all women at times of need. Quality PAC services should be rendered by skilled health care workers in a facility which is accessible and well equipped with functional equipments and updated guidelines. Recommendations: The study therefore recommends that measures should be taken to ensure the provision of quality PAC services. The PAC services should be accessible with the increased number of facilities, adequate trained health care workers with functional equipment and guidelines. Health care workers must receive training and management support to enhance quality PAC services. Privacy and respect must be maintained during provision of PAC services to ensure quality of care and increase demand. There must be continuous community awareness about PAC services which will encourage early-seeking behavior, and reduce fear of stigma and discrimination by the providers of PAC services before the complications arises. This study did not cover all the districts to identify the challenges on delaying PAC service. Therefore, this study recommends additional clinical, operations and community research which will give broader details and understanding on the challenges that cause delay for seeking immediate post abortion care services. / NRF

Thesis (PhD (Education)--Stellenbosch University, 2008. / ENGLISH ABSTRACT: Before the implementation of abortion legislation in South Africa in February 1997, illegal abortions were the only way out for women with unwanted pregnancies. Because of the high morbidity and mortality rate of the women concerned, abortion legislation was implemented with the aim of ending illegal abortions in South Africa by having abortions carried out legally on request in designated health care facilities. The abortion legislation stipulates that registered nurses who have undergone the proposed abortion care training may terminate a pregnancy upon request of a woman during the first twelve weeks of the gestation period of her pregnancy. Although legislation authorises registered nurses to carry out first trimester abortions, an inadequate number of nurses are being trained in the Western Cape to provide pregnant women with guidance and counselling services, carry out the abortions and/or refer problem cases. Since the implementation of the abortion legislation no real attempts have been made by higher education institutions in the Western Cape to offer abortion care training for nurses. A need has therefore been identified to develop a comprehensive training framework for higher education institutions in the Western Cape for the training of nurses in abortion care. The case study was used as research design and the specific unit of analysis on which the researcher focused were the registered nurses who had received training in abortion care and the context in which they provide abortion care at the various levels of service provision in the different regions of the Western Cape. A random, stratified sample (non-proportional) was taken of the designated state health care facilities in the Western Cape, as well as a non-probability purposive sampling of registered nurses who provide abortion care, a non-probability convenience sample of women who have received abortion care and a non-probability purposive sampling of final-year pre-registration nursing students. Data was generated by means of questionnaires to the women who received abortions and/or counselling, the registered nurses who carried out abortions as well as final-year preregistration nursing students. A checklist was used to observe the abortions that were carried out by registered nurses in an objective and non-participatory manner and semi-structured interviews were conducted with various role-players in abortion care and training. The main findings of this study indicate that the necessary infrastructure within which the services could be provided according to the abortion legislation was adequate, but that the ongoing shortage of trained health care practitioners hampers the abortion care services. Only 10 (n=10) of the 15 certified nurses employed in state health care facilities actively offered abortion care services in the various designated facilities in the Western Cape. Deficiencies were identified in the existing provincial protocol and it was clear that some of the guidelines are either not in use or have become obsolete in the light of new research findings. It was found that midwives with appropriate and effective training are the ideal category of health practitioner for the provision of abortion care. The certified nurses who have been trained by the various regional offices of the Department of Health: Western Cape are skilled in carrying out the abortion procedure, but the other aspects of abortion care, that are mainly carried out by other categories of nurses, will probably require greater attention. The recommendations, which are based on a thorough literature study as well as on the findings and conclusions that arose from the empirical part of this study, have been included in a training framework. The researcher recommends that the training framework provide the basis for the development of a formal programme or programmes for the training of nurses in abortion care at higher education institutions. The purpose of the proposed framework is therefore to determine the context within which curriculation ought to take place, and to provide a focus or format for those who develop the curriculum for prospective students. / AFRIKAANSE OPSOMMING: Voor die implementering van aborsiewetgewing in Februarie 1997 was onwettige aborsies die enigste uitweg vir vroue met ongewenste swangerskappe in Suid-Afrika. Weens die hoë morbiditeit- en mortaliteitsyfer van die betrokke vroue is aborsiewetgewing geïmplementeer met die doel om onwettige aborsies in Suid-Afrika te beëindig en aborsies op versoek wettiglik in aangewysde gesondheidsorgfasiliteite uit te voer. Die aborsiewetgewing stipuleer dat verpleegkundiges wat die voorgestelde aborsiesorgopleiding ondergaan het, ‘n swangerskap kan beëindig op versoek van ‘n vrou gedurende die eerste 12 weke van die draagtyd van haar swangerskap. Ten spyte van wetgewing wat verpleegkundiges magtig om eerste trimester aborsies uit te voer, word daar om verskeie redes onvoldoende aantal verpleegkundiges in die Wes-Kaap opgelei wat voorligting en berading aan swanger vroue gee, die aborsies uitvoer en/of probleemgevalle moet verwys. Geen daadwerklike pogings is sedert die inwerkingstelling van die aborsiewetgewing deur hoëronderwysinstellings in die Wes-Kaap aangewend om aborsiesorgopleiding vir verpleegkundiges aan te bied nie. Derhalwe is ’n behoefte geïdentifiseer om ’n omvattende opleidingsraamwerk vir hoëronderwysinstellings in die Wes- Kaap te ontwikkel vir die opleiding van verpleegkundiges in aborsiesorg. Die gevallestudie is as navorsingsontwerp gebruik en die spesifieke eenheid van analise waarop gefokus is was die verpleegkundiges wat opleiding in aborsiesorg ontvang het en die konteks waarbinne hulle aborsiesorg lewer by die onderskeie vlakke van dienslewering in die onderskeie streke van die Wes-Kaap. ’n Ewekansige, gestratifiseerde steekproef (nie-proporsioneel) is geneem van die aangewysde staatsgesondheidsorgfasiliteite in die Wes-Kaap, sowel as ’n nie-waarskynlike, doelbewuste steekproefneming van verpleegkundiges wat aborsiesorg verskaf, ’n nie-waarskynlike gerieflikheidsteekproefneming van vroue wat aborsiesorg ontvang het en ’n nie-waarskynlike, doelbewuste steekproefneming van finalejaar voorregistrasie verpleegstudente. Data is gegenereer met behulp van vraelyste aan onderskeidelik die vroue wat aborsies en/of berading ontvang het, die verpleegkundiges wat aborsies uitgevoer het, asook finalejaar voorregistrasie verpleegstudente. ’n Kontrolelys is gebruik om die aborsies wat deur verpleegkundiges uitgevoer is objektief en nie-deelnemend te observeer en semigestruktureerde onderhoude is met verskeie rolspelers in aborsiesorgdienste en -opleiding gevoer. Die hoofbevindings van hierdie studie dui daarop dat die nodige infrastruktuur waarbinne die dienste ingevolge die aborsiewetgewing gelewer kon word voldoende was, maar dat die voortslepende tekort aan opgeleide gesondheidsorgpraktisyns die aborsiesorgdienste kortwiek. Slegs 10 (n=10) van die 15 gesertifiseerde verpleegkundiges in diens van staatsgesondheidsorgfasiliteite het aktief aborsiesorgdienste aangebied in die onderskeie aangewysde fasiliteite in die Wes-Kaap. Leemtes is in die bestaande provinsiale protokol geïdentifiseer en dit het in die lig van nuwe navorsingsbevindings geblyk dat sommige van die riglyne óf nie in gebruik was nie, óf dat hulle intussen verouderd geraak het. Daar is bevind dat vroedvroue met toepaslike en doeltreffende opleiding die ideale kategorie gesondheidsorgpraktisyn is vir die verskaffing van aborsiesorg. Die gesertifiseerde verpleegkundiges wat deur die Departement van Gesondheid: Wes-Kaap se onderskeie streekskantore opgelei is, is vaardig in die uitvoer van die aborsieprosedure as sulks, maar die ander aspekte van aborsiesorg, wat meestal ook deur ander kategorieë verpleegkundiges uitgevoer word, sal waarskynlik groter aandag moet kry. Die aanbevelings is gegrond op ’n deeglike literatuurstudie sowel as op die bevindings en gevolgtrekkings wat uit die empiriese gedeelte van hierdie studie spruit en is vervat in ’n opleidingsraamwerk. Die navorser beveel aan dat die opleidingsraamwerk die grondslag sal bied vir die ontwikkeling van ’n formele program of programme vir die opleiding van verpleegkundiges in aborsiesorg aan hoëronderwysinstellings. Die doel van die voorgestelde raamwerk is dus om die konteks te bepaal waarbinne kurrikulering moet plaasvind, asook om ’n fokus of formaat te verskaf vir diegene wat die kurrikulum vir voornemende studente ontwikkel.