KNOWLEDGE AND PRACTICE OF POST-ABORTION CARE BY MIDWIVES IN SELECTED PRIMARY HEALTH CARE FACILITIES IN ASHANTI REGION, GHANA
Main Article Content
Abstract
In Ghana, abortion-related mortality is considered a major public health issue that needs to be addressed. Midwives have been trained to safely and effectively provide post-abortion care in the country, yet the expected decline in maternal deaths from abortion complications especially in the rural settings is yet to be realized. Primary Healthcare (PHC) facility is the first point of contact for the rural populace, yet there is minimal evidence on the capacity of midwives serving there to provide post-abortion care. This study assessed the knowledge and practice of post abortion care among midwives in selected primary healthcare (PHC) facilities in Ashanti region of Ghana. A cross sectional descriptive survey design was utilized for the study, and a multi-staged sampling technique was used to select 16 PHCs comprising both government (11) and private (5) owned, from which 112 participants were recruited. A pre-tested structured, self-developed questionnaire was employed to obtain information from the study participants. Obtained data were analyzed using SPSS version 21. A total of 109 questionnaires were accurately completed out of 112 administered, giving a response rate of 97.3%. The midwives’ knowledge of post abortion care (PAC) was mainly in the areas of PAC as treatment for abortion complications 49(36%), while knowledge on the other PAC components was low. Only 63(58%) of the respondents had training on PAC, which was basically on the use of Manual Vacuum Aspiration (MVA) to complete incomplete abortion 52(41%). Among the 70(64%) respondents who indicated that their PHC facilities provide PAC services, only 72(66%) of them actually carried out post abortion care. Reasons advanced by the other 39(36%) who never carried out PAC were lack of; confidence 30(815), skills 27(73%), and knowledge 20(54%). The study recommended the training of midwives serving in PHCs in all components of post-abortion care as a feasible strategy for decentralizing PAC services and reaching out to the neglected rural populace. This aspect of reproductive health need to be re-emphasized in midwifery training curricula, buttress with regular mandatory continuing professional development in the area to improve skills.
Keywords:
Post abortion care, knowledge, practice, midwives, Primary Healthcare facility
Article Details
How to Cite
NSEMO, Alberta David et al.
KNOWLEDGE AND PRACTICE OF POST-ABORTION CARE BY MIDWIVES IN SELECTED PRIMARY HEALTH CARE FACILITIES IN ASHANTI REGION, GHANA.
Medical Research Archives, [S.l.], v. 9, n. 1, jan. 2021.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/2326>. Date accessed: 18 apr. 2024.
doi: https://doi.org/10.18103/mra.v9i1.2326.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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3. Adinma, J.I., Ikeako,L., Adinma, E.D., Ezeama, C.O. and Ugboaja, J.O.(2010). Awareness and practice of post abortion care services among health care professionals in southeastern Nigeria. Southeast Asian Journal of Tropical Medicine and Public Health,41(3),696.
4. Afhami, N., Bahadoran, P., Taleghani, H.R. and Nekuei, N. (2016). The knowledge and attitudes of midwives regarding legal and religious commandments on induced abortion and their relationship with some demographic characteristics. Iranian journal of nursing and midwifery research, 21(2), 177.
5. Aniteye, P., O’Brien, B. and Mayhew, S.H.(2016). Stigmatized by association: challenges for abortion service providers in Ghana. BMC health services research,16(1),486.
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7. "Ashanti Region". GhanaDistricts. Retrieved 29 December 2019
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9. Asamoah, B.O., Moussa, K.M., Stafström, M. and Musinguzi, G.(2011). Distribution of causes of maternal mortality among different socio-demographic groups in Ghana; a descriptive study. BMC public health11(1),159.
10. Amu, H. and Nyarko, S.H.(2016): Preparedness of health care professionals in preventing maternal mortality at a public health facility in Ghana: a qualitative study. BMC Health Services Research, 16(1),252.
11. Bacon, A., Ellis, C., Rostoker, J.F. and Olaro, A.A. (2014): Exploring the role of midwives in Uganda’s postabortion care: Current practice, barriers, and solutions. International Journal of Childbirth, 4(1),4-16.
12. Baiden, F., Amponsa-Achiano, K., Oduro, A.R., Mensah, T.A., Baiden, R. and Hodgson, A. (2006): Unmet need for essential obstetric services in a rural district in northern Ghana: complications of unsafe abortions remain a major cause of mortality. Public health,120(5),421-6.
13. Baig, M. Jan, R., Lakhani, A., Ali, S.A., Mubeen, K., Ali, S.S. and Adnan, F.(2017). Knowledge, Attitude, and Practices of Mid-Level Providers regarding Post Abortion Care in Sindh. Pakistan. Journal of Asian Midwives (JAM),4(1),21-34.
14. Billings, D.L., Ankrah, V., Baird, T.L., Taylor, J.E., Ababio, K.P. and Ntow, S.(1999). Midwives and comprehensive postabortion care in Ghana. Postabortion care: Lessons learned from operations research. New York, The Population Council.
15. Blum, J., Winikoff, B., Gemzell‐Danielsson, K., Ho, P.C., Schiavon, R. and Weeks, A.(2007). Treatment of incomplete abortion and miscarriage with misoprostol. International Journal of Gynecology & Obstetrics. 99,S186-9.
16. Campbell, M. and Holden, M. (2006).Global availability of misoprostol. International Journal of Gynecology & Obstetrics,94,S151-2.
17. Chen, L., Evans, T., Anand, S., Boufford, J.I., Brown, H., Chowdhury, M., Cueto, M., Dare, L., Dussault, G., Elzinga, G. and Fee,E.(2004). Human resources for health: overcoming the crisis. The Lancet,364(9449),1984-90.
18. Clark, K., Mitchell, E.H. and Aboagye, P.K.(2010). Return on investment for essential obstetric care training in Ghana: Do trained public sector midwives deliver postabortion care?. Journal of midwifery & women's health,55(2),153-61.
19. Corbett, M.R. and Turner, K.L.(2003). Essential elements of postabortion care: origins, evolution and future directions. International Family Planning Perspectives,29(3),106-11.
20. Eades, C.A., Brace, C., Osei, L. and LaGuardia, K.D.(1993). Traditional birth attendants and maternal mortality in Ghana. Social science & medicine,36(11),1503-7.
21. Esia-Donkoh, K., Darteh, E.K., Blemano, H. and Asare, H. (2015): Who cares? Pre and post abortion experiences among young females in Cape Coast Metropolis, Ghana. African journal of reproductive health,19(2),43-51.
22. Etuk, S.J., Ebong, I.F. and Okonofua, F.E.(2003). Knowledge, attitude and practice of private medical practitioners in Calabar towards post-abortion care. African journal of reproductive health, 55-64.
23. Faúndes, A.(2010). Unsafe abortion–the current global scenario. Best practice & research. Clinical obstetrics & gynaecology,24(4),467-77.
24. Fullerton, J., Butler, M.M., Aman, C., Reid, T. and Dowler, M. (2018): Abortion-related care and the role of the midwife: a global perspective. International journal of women's health,10,751.
25. Gemzell-Danielsson, K., Fiala, C. and Weeks, A.(2007). Misoprostol: first-line therapy for incomplete miscarriage in the developing world. BJOG, 114(11),1337-9.
26. Gopal, R. and Bedi, S.S.(2014). Impact of hospital services on outpatient satisfaction. International Journal of Research in Business Management,2(4),37-44.
27. Graff, M., and Amoyaw, D.A.(2009). Barriers to sustainable MVA supply in Ghana: challenges for the low-volume, low-income providers. African Journal of Reproductive Health,13(4).
28. “GSS and GHS and Calverton, Macro International,” in Proceedings of the GSS and GHS and Calverton, Macro International, Accra, Ghana, 2007.
29. Hessini, L.(2014). A learning agenda for abortion stigma: recommendations from the Bellagio expert group meeting. Women & health,54(7),617-21.
30. Hessini, L., Brookman-Amissah, E. and Crane, B.B. (2006). Global Policy Change and Women\'s Access to safe abortion: The impact of the World Health Organization\'s guidance in African. African journal of reproductive health,10(3),14-27.
31. Holcombe, S.J., Berhe, A. and Cherie, A.(2015). Personal beliefs and professional responsibilities: Ethiopian midwives' attitudes toward providing abortion services after legal reform. Studies in family planning,46(1),73-95.
32. Homaifar, N., Freedman, L. and French, V. (2017). “She's on her own”: a thematic analysis of clinicians' comments on abortion referral. Contraception, 95(5),470-6.
33. International confideration of midwives’ position statement: midwives’ provision of abortion-related services.(2001) (updated 2014) Available from https://International midwivws.org/assets/
34. Kim, C.R., Tunçalp, Ö., Ganatra, B. and Gülmezoglu, A.M.(2016): WHO MCS-A Research Group. WHO Multi-Country survey on abortion-related morbidity and mortality in health facilities: study protocol. BMJ global health,1(3):e000113.
35. Kumbi, S., Melkamu, Y., and Yeneneh, H.(2008): Quality of post-abortion care in public health facilities in Ethiopia. Ethiopian Journal of Health Development, 22(1),26-33.
36. McDougall, J., Fetters, T., Clark, K.A. and Rathavy, T.(2009). Determinants of contraceptive acceptance among Cambodian abortion patients. Studies in family planning,40(2),123-32.
37. Melkamu, Y., Enquselassie, F., Ali, A., Gebresilassie, H. and Yusuf, L.(2005): Assessment of quality of post abortion care in government hospitals in Addis Ababa, Ethiopia. Ethiopian Medical Journal,43(3), 137–149.
38. Melkamu, Y., Betre, M. and Tesfaye, S.(2010): Utilization of post-abortion care services in three regional states of Ethiopia. Ethiopian Journal of Health Development,24(1).
39. Miller, S., Billings, D.L. and Clifford, B.(2002): Midwives and postabortion care: experiences, opinions, and attitudes among participants at the 25th Triennial Congress of the International Confederation of Midwives. Journal of Midwifery & Women’s Health, 47(4),247-55.
40. Nabudere, H., Asiimwe, D.and Mijumbi, R.(2011). Task shifting in maternal and child health care: an evidence brief for Uganda. International journal of technology assessment in health care,27(2),173-9.
41. Nalwadda, G., Mirembe, F., Tumwesigye, N.M., Byamugisha, J. and Faxelid, E.(2011). Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives. BMC health services research,11(1),220.
42. Nath, S.(ND) Supplementary report. Case studies: Getting Research into Policy and Practice (GRIPP).
43. Paul, M., Gemzell-Danielsson, K., Kiggundu, C., Namugenyi, R. and Klingberg-Allvin, M.(2014). Barriers and facilitators in the provision of post-abortion care at district level in central Uganda–a qualitative study focusing on task sharing between physicians and midwives. BMC health services research,14(1),28.
44. Postabortion Care Consortium (2002): Essential elements of postabortion care: an expanded and updated model. Postabortion Care Consortium, PAC in Action. 2002 (2).
45. Rominski, S.D. and Lori, J.R.(2014). Abortion care in Ghana: a critical review of the literature. African journal of reproductive health,18(3),17-35.
46. Sedgh, G., Bearak, J., Singh, S., Bankole, A., Popinchalk, A., Ganatra, B., Rossier, C., Gerdts, C., Tunçalp, Ö., Johnson Jr., B.R. and Johnston, H.B.(2016): Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. The Lancet, 388(10041), 258-67.
47. Shwekerela, B., Kalumuna, R., Kipingili, R., Mashaka, N., Westheimer, E., Clark,W.and Winikoff, B.(2007). Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. BJOG: International Journal of Obstetrics & Gynaecology,114(11),1363-7.
48. Solo, J., Billings, D.L., Aloo‐Obunga, C., Ominde, A. and Makumi, M.(1999). Creating linkages between incomplete abortion treatment and family planning services in Kenya. Studies in family planning, 30(1),17-27.
49. Sundaram, A., Juarez, F., Bankole, A.and Singh, S.(2012): Factors associated with abortion‐seeking and obtaining a safe abortion in Ghana. Studies in Family Planning,43(4),273-86.
50. Taylor, J., Diop, A., Blum, J., Dolo, O. and Winikoff, B.(2011). Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana. International Journal of Gynecology & Obstetrics,112(1),40-4.
51. Tesfaye, G.and Oljira, L. (2013). Post abortion care quality status in health facilities of Guraghe zone, Ethiopia. Reproductive health,10(1),35.
52. Van Teijlingen, E. and Hundley, V.(2002). The importance of pilot studies. Nursing Standard (through 2013),16(40),33.
53. Warriner, I.K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., Huong, N.M., Vy, N.D. and Seuc, A.H.( 2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. The Lancet, 368(9551),1965-1972.
54. World Health Organisation (2016): “Fact sheet: Maternal mortality,” http://www.who.int/mediacentre/factsheets/fs348/en/.
55. World Health Organization (2012). Safe abortion: technical and policy guidance for health systems. WHO. Geneva. Available from: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
56. World Health Organization. Safe abortion: technical and policy guidance for health systems.(2012).WHO.Geneva. Available from: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
57. Zainullah, P., Ansari, N., Yari, K., Azimi, M., Turkmani, S., Azfar, P., LeFevre, A., Mungia, J., Gubin, R., Kim, Y.M. and Bartlett, L.(2014). Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program. Midwifery,30(10),1056-62.
2. Adde, K.S., Darteh, E.K., Kumi-Kyereme, A. and Amu, H.(2018). Responsiveness of Health Professionals to Postabortion Care at a Regional Level Hospital in Ghana: A Qualitative Study of Patients’ Self-Reports. International journal of reproductive medicine.
3. Adinma, J.I., Ikeako,L., Adinma, E.D., Ezeama, C.O. and Ugboaja, J.O.(2010). Awareness and practice of post abortion care services among health care professionals in southeastern Nigeria. Southeast Asian Journal of Tropical Medicine and Public Health,41(3),696.
4. Afhami, N., Bahadoran, P., Taleghani, H.R. and Nekuei, N. (2016). The knowledge and attitudes of midwives regarding legal and religious commandments on induced abortion and their relationship with some demographic characteristics. Iranian journal of nursing and midwifery research, 21(2), 177.
5. Aniteye, P., O’Brien, B. and Mayhew, S.H.(2016). Stigmatized by association: challenges for abortion service providers in Ghana. BMC health services research,16(1),486.
6. Ansari, N., Zainullah, P., Kim, Y.M., Tappis, H., Kols, A., Currie, S., Haver, J., van Roosmalen, J., Broerse, J.E. and Stekelenburg, J.(2015). Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study. BMC pregnancy and childbirth,15(1),6.
7. "Ashanti Region". GhanaDistricts. Retrieved 29 December 2019
8. Ashanti Region. Geohive.com.
9. Asamoah, B.O., Moussa, K.M., Stafström, M. and Musinguzi, G.(2011). Distribution of causes of maternal mortality among different socio-demographic groups in Ghana; a descriptive study. BMC public health11(1),159.
10. Amu, H. and Nyarko, S.H.(2016): Preparedness of health care professionals in preventing maternal mortality at a public health facility in Ghana: a qualitative study. BMC Health Services Research, 16(1),252.
11. Bacon, A., Ellis, C., Rostoker, J.F. and Olaro, A.A. (2014): Exploring the role of midwives in Uganda’s postabortion care: Current practice, barriers, and solutions. International Journal of Childbirth, 4(1),4-16.
12. Baiden, F., Amponsa-Achiano, K., Oduro, A.R., Mensah, T.A., Baiden, R. and Hodgson, A. (2006): Unmet need for essential obstetric services in a rural district in northern Ghana: complications of unsafe abortions remain a major cause of mortality. Public health,120(5),421-6.
13. Baig, M. Jan, R., Lakhani, A., Ali, S.A., Mubeen, K., Ali, S.S. and Adnan, F.(2017). Knowledge, Attitude, and Practices of Mid-Level Providers regarding Post Abortion Care in Sindh. Pakistan. Journal of Asian Midwives (JAM),4(1),21-34.
14. Billings, D.L., Ankrah, V., Baird, T.L., Taylor, J.E., Ababio, K.P. and Ntow, S.(1999). Midwives and comprehensive postabortion care in Ghana. Postabortion care: Lessons learned from operations research. New York, The Population Council.
15. Blum, J., Winikoff, B., Gemzell‐Danielsson, K., Ho, P.C., Schiavon, R. and Weeks, A.(2007). Treatment of incomplete abortion and miscarriage with misoprostol. International Journal of Gynecology & Obstetrics. 99,S186-9.
16. Campbell, M. and Holden, M. (2006).Global availability of misoprostol. International Journal of Gynecology & Obstetrics,94,S151-2.
17. Chen, L., Evans, T., Anand, S., Boufford, J.I., Brown, H., Chowdhury, M., Cueto, M., Dare, L., Dussault, G., Elzinga, G. and Fee,E.(2004). Human resources for health: overcoming the crisis. The Lancet,364(9449),1984-90.
18. Clark, K., Mitchell, E.H. and Aboagye, P.K.(2010). Return on investment for essential obstetric care training in Ghana: Do trained public sector midwives deliver postabortion care?. Journal of midwifery & women's health,55(2),153-61.
19. Corbett, M.R. and Turner, K.L.(2003). Essential elements of postabortion care: origins, evolution and future directions. International Family Planning Perspectives,29(3),106-11.
20. Eades, C.A., Brace, C., Osei, L. and LaGuardia, K.D.(1993). Traditional birth attendants and maternal mortality in Ghana. Social science & medicine,36(11),1503-7.
21. Esia-Donkoh, K., Darteh, E.K., Blemano, H. and Asare, H. (2015): Who cares? Pre and post abortion experiences among young females in Cape Coast Metropolis, Ghana. African journal of reproductive health,19(2),43-51.
22. Etuk, S.J., Ebong, I.F. and Okonofua, F.E.(2003). Knowledge, attitude and practice of private medical practitioners in Calabar towards post-abortion care. African journal of reproductive health, 55-64.
23. Faúndes, A.(2010). Unsafe abortion–the current global scenario. Best practice & research. Clinical obstetrics & gynaecology,24(4),467-77.
24. Fullerton, J., Butler, M.M., Aman, C., Reid, T. and Dowler, M. (2018): Abortion-related care and the role of the midwife: a global perspective. International journal of women's health,10,751.
25. Gemzell-Danielsson, K., Fiala, C. and Weeks, A.(2007). Misoprostol: first-line therapy for incomplete miscarriage in the developing world. BJOG, 114(11),1337-9.
26. Gopal, R. and Bedi, S.S.(2014). Impact of hospital services on outpatient satisfaction. International Journal of Research in Business Management,2(4),37-44.
27. Graff, M., and Amoyaw, D.A.(2009). Barriers to sustainable MVA supply in Ghana: challenges for the low-volume, low-income providers. African Journal of Reproductive Health,13(4).
28. “GSS and GHS and Calverton, Macro International,” in Proceedings of the GSS and GHS and Calverton, Macro International, Accra, Ghana, 2007.
29. Hessini, L.(2014). A learning agenda for abortion stigma: recommendations from the Bellagio expert group meeting. Women & health,54(7),617-21.
30. Hessini, L., Brookman-Amissah, E. and Crane, B.B. (2006). Global Policy Change and Women\'s Access to safe abortion: The impact of the World Health Organization\'s guidance in African. African journal of reproductive health,10(3),14-27.
31. Holcombe, S.J., Berhe, A. and Cherie, A.(2015). Personal beliefs and professional responsibilities: Ethiopian midwives' attitudes toward providing abortion services after legal reform. Studies in family planning,46(1),73-95.
32. Homaifar, N., Freedman, L. and French, V. (2017). “She's on her own”: a thematic analysis of clinicians' comments on abortion referral. Contraception, 95(5),470-6.
33. International confideration of midwives’ position statement: midwives’ provision of abortion-related services.(2001) (updated 2014) Available from https://International midwivws.org/assets/
34. Kim, C.R., Tunçalp, Ö., Ganatra, B. and Gülmezoglu, A.M.(2016): WHO MCS-A Research Group. WHO Multi-Country survey on abortion-related morbidity and mortality in health facilities: study protocol. BMJ global health,1(3):e000113.
35. Kumbi, S., Melkamu, Y., and Yeneneh, H.(2008): Quality of post-abortion care in public health facilities in Ethiopia. Ethiopian Journal of Health Development, 22(1),26-33.
36. McDougall, J., Fetters, T., Clark, K.A. and Rathavy, T.(2009). Determinants of contraceptive acceptance among Cambodian abortion patients. Studies in family planning,40(2),123-32.
37. Melkamu, Y., Enquselassie, F., Ali, A., Gebresilassie, H. and Yusuf, L.(2005): Assessment of quality of post abortion care in government hospitals in Addis Ababa, Ethiopia. Ethiopian Medical Journal,43(3), 137–149.
38. Melkamu, Y., Betre, M. and Tesfaye, S.(2010): Utilization of post-abortion care services in three regional states of Ethiopia. Ethiopian Journal of Health Development,24(1).
39. Miller, S., Billings, D.L. and Clifford, B.(2002): Midwives and postabortion care: experiences, opinions, and attitudes among participants at the 25th Triennial Congress of the International Confederation of Midwives. Journal of Midwifery & Women’s Health, 47(4),247-55.
40. Nabudere, H., Asiimwe, D.and Mijumbi, R.(2011). Task shifting in maternal and child health care: an evidence brief for Uganda. International journal of technology assessment in health care,27(2),173-9.
41. Nalwadda, G., Mirembe, F., Tumwesigye, N.M., Byamugisha, J. and Faxelid, E.(2011). Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives. BMC health services research,11(1),220.
42. Nath, S.(ND) Supplementary report. Case studies: Getting Research into Policy and Practice (GRIPP).
43. Paul, M., Gemzell-Danielsson, K., Kiggundu, C., Namugenyi, R. and Klingberg-Allvin, M.(2014). Barriers and facilitators in the provision of post-abortion care at district level in central Uganda–a qualitative study focusing on task sharing between physicians and midwives. BMC health services research,14(1),28.
44. Postabortion Care Consortium (2002): Essential elements of postabortion care: an expanded and updated model. Postabortion Care Consortium, PAC in Action. 2002 (2).
45. Rominski, S.D. and Lori, J.R.(2014). Abortion care in Ghana: a critical review of the literature. African journal of reproductive health,18(3),17-35.
46. Sedgh, G., Bearak, J., Singh, S., Bankole, A., Popinchalk, A., Ganatra, B., Rossier, C., Gerdts, C., Tunçalp, Ö., Johnson Jr., B.R. and Johnston, H.B.(2016): Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. The Lancet, 388(10041), 258-67.
47. Shwekerela, B., Kalumuna, R., Kipingili, R., Mashaka, N., Westheimer, E., Clark,W.and Winikoff, B.(2007). Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. BJOG: International Journal of Obstetrics & Gynaecology,114(11),1363-7.
48. Solo, J., Billings, D.L., Aloo‐Obunga, C., Ominde, A. and Makumi, M.(1999). Creating linkages between incomplete abortion treatment and family planning services in Kenya. Studies in family planning, 30(1),17-27.
49. Sundaram, A., Juarez, F., Bankole, A.and Singh, S.(2012): Factors associated with abortion‐seeking and obtaining a safe abortion in Ghana. Studies in Family Planning,43(4),273-86.
50. Taylor, J., Diop, A., Blum, J., Dolo, O. and Winikoff, B.(2011). Oral misoprostol as an alternative to surgical management for incomplete abortion in Ghana. International Journal of Gynecology & Obstetrics,112(1),40-4.
51. Tesfaye, G.and Oljira, L. (2013). Post abortion care quality status in health facilities of Guraghe zone, Ethiopia. Reproductive health,10(1),35.
52. Van Teijlingen, E. and Hundley, V.(2002). The importance of pilot studies. Nursing Standard (through 2013),16(40),33.
53. Warriner, I.K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., Huong, N.M., Vy, N.D. and Seuc, A.H.( 2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. The Lancet, 368(9551),1965-1972.
54. World Health Organisation (2016): “Fact sheet: Maternal mortality,” http://www.who.int/mediacentre/factsheets/fs348/en/.
55. World Health Organization (2012). Safe abortion: technical and policy guidance for health systems. WHO. Geneva. Available from: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
56. World Health Organization. Safe abortion: technical and policy guidance for health systems.(2012).WHO.Geneva. Available from: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf
57. Zainullah, P., Ansari, N., Yari, K., Azimi, M., Turkmani, S., Azfar, P., LeFevre, A., Mungia, J., Gubin, R., Kim, Y.M. and Bartlett, L.(2014). Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program. Midwifery,30(10),1056-62.