Introduction
An estimated 8.3 million induced abortions took place in Africa annually between 2010 and 20141; less than 10% of which were a safe termination of pregnancy (TOP) following WHO guidelines.2–4 Safe TOP can reduce maternal mortality because they reduce recourse to unsafe abortion and because contraceptive counselling can help prevent future unwanted pregnancies. While all abortions, either induced or spontaneous, may need postabortion care (PAC) to treat arising complications, the probability of requiring PAC is greatest for unsafe abortions.
Zambia is one of the few countries in Africa to permit legal TOP on a wide range of grounds. The Termination of Pregnancy Act of 1972 states that an abortion may take place if the continuation of the pregnancy involves a risk to the pregnant woman’s life, physical or mental health; a risk to the health of any existing children; or if there is a substantial risk of birth abnormalities.5 6 Three doctors’ signatures are required, although this is waived if one doctor believes TOP is immediately necessary to protect the woman’s health. Despite this, the law is still a matter of contention, and in recent years, there have been attempts to amend the Zambian constitution with a draft article that defines life as beginning at conception7 8; the political environment remains sensitive.
Zambia has a high burden of abortion-related morbidity and mortality due to the multiple barriers that exist in accessing safe, legal services: the abortion-related near-miss rate across Central, Copperbelt and Lusaka provinces is 72 per 100 000 women, and the abortion-related near-miss ratio is 450 per 100 000 live births.9 Zambia identifies as a country with a strong Christian culture.10 Women in Zambia are generally unaware that a TOP can be legally obtained in a wide range of circumstances, which delays and limits care-seeking.11 Economic and social costs are high, and the procedure is strongly socially stigmatised.12 Women must often travel long distances to reach a health facility that can provide the procedure. There is a shortage of health providers: in Central Province, where our study took place, there is one medical doctor for every 111 648 people.13 Within health facilities, conscientious objection, lack of training, high staff turnover and stigma all present further barriers to care.14 15
While the many barriers to accessing abortion services in legally restrictive settings are relatively well documented, much less is known about the levels of provision and quality of care within health systems in these settings. The WHO has used the signal functions approach to document provision of emergency obstetric care for several decades,16 and recently an extension of this approach has been proposed for abortion services.17 The advantages of using a signal functions approach are: the ability to assess health system capabilities, make comparisons across time and place and describe service provision in terms of equity while requiring relatively little data and avoiding placing undue burden on data collection systems.17
The aim of this study was to characterise the inputs for service provision for TOP and PAC services in Central Province, Zambia, in 2016 using the signal functions approach. In addition, we had the following objectives: (1) to evaluate time trends, where data permitted; (2) to estimate health facilities’ potential capability to provide services under three different policy assumptions; and (3) to examine geographic access to TOP and PAC services by linking our facility data with the last population census.