Effect of clinicians training on their knowledge of abortion and postabortion care in six hospitals in Rwanda

Abstract

Background:

Complications of unsafe abortion are public health issue and account for 13% of maternal mortalities globally. Maternal mortality in Rwanda remains high at 203/100,000 live births. Prevalence of unintended pregnancy in Rwanda is estimated at 12%, abortion-related complications are estimated at 10.7 per 1000 and abortion-related maternal mortality remains high (8%). Existing literature suggests that many clinicians face challenges in delivering reproductive health services, including abortion and postabortion care. These challenges often caused by a lack of confidence and insufficient training.

Objective:

This study aimed to assess the effect of training medical doctors on their knowledge of abortion and postabortion care in Rwanda.

Design:

A quasi-experimental design was used.

Methods:

We trained clinicians from six hospitals in Rwanda on abortion and postabortion care using updated national guidelines and the WHO Safe Abortion Care Guideline. Clinicians were trained in 3-h-long sessions over 3 months including lecture and self-learning using shared guidelines books during this period. Pretest and posttest were implemented. In total, four training sessions were held. Training was theoretical only. We compared pretest and posttest scores using paired t-test; p value <0.05 was considered statistically significant.

Results:

Thirty medical doctors from district and referral hospitals were trained. There was an increase in marks between pretest and posttest. This increase was statistically significant among trainees from three district hospitals with p values 0.046, <0.001, and <0.001, respectively. This increase was statistically significant among both gender groups of participants with p value of 0.005 and 0.001 for male and female trainees, respectively. There was no statistically increase in marks for trainees in teaching hospitals (p value = 0.168).

Conclusion:

We found a statistical increase in marks comparing pre- and posttest scores for clinicians attending district hospitals. This increase was observed in both male and female trainees. This increase in marks suggests that the training had a positive impact on clinicians’ knowledge that impacted their decision making and elaboration of management plan for abortion and postabortion care provision.

Background

Worldwide, there is a strategic goal to reduce maternal morbidity and mortality. Sustainable Development Goals (SDGs) suggest a reduction in the global maternal mortality ratio by 2030 to less than 70 per 100,000 live births. ¹ Complications of unsafe abortion are a public health issue and account for 13% of maternal mortalities globally. ² Unsafe abortion is defined as a procedure of terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. ³ The most current estimates suggest that unsafe abortion accounts for half of abortions globally and most abortion-related complications and deaths occur in Africa. ⁴ Between 2015 and 2019, around 73.3 million abortions occurred each year worldwide with around 8 million abortions reported in sub-Saharan Africa. ⁴ Globally, 45.1% of abortions performed are considered unsafe, and 75.6% of abortions performed in Africa are classified as unsafe. ⁴ Abortion-related complications contribute to maternal morbidity and mortality in sub-Saharan African countries. ⁴ The prevalence of unintended pregnancy in Rwanda is estimated at 12%, abortion-related complications are estimated at 10.7 per 1000, and abortion-related maternal mortality remains high, 203/100,000 live births (8%).^5,6

Maternal mortality in Rwanda almost triples the SDG 3.1 target for global maternal mortality rate by 2030. ⁵ This ratio of maternal mortality in Rwanda indicates a significant gap for maternal mortality reduction which needs to be addressed. Unsafe abortion not only contributes to maternal morbidity and mortality but also leads to domestic violence, child abuse, family conflicts and psychological trauma. ⁷ Considering Rwanda’s high mortality rate of 203/100,000 live births and pressing need to improve maternal health services, taking into consideration of the experiences of healthcare professionals who are in charge of providing safe abortion services is crucial. Regular and continuous training may impact the quality of care delivery to those in need of abortion and postabortion care. ⁸

Safe abortion and postabortion care are needed to address the hazards of unsafe abortion.^9,10 Standards exist for abortion care. Established in 1993, the Post Abortion Care Consortium comprises five interrelated elements: partnership between communities and service providers, client-centered counseling at appropriate times during service delivery, treatment with emphasis on pain management, family planning, and links to reproductive and other health services. ⁹ The abortion law in Rwanda was recently revised to allow registered medical doctors to provide abortion services under the following circumstances: Pregnant individual is a minor/under the age of 18, in case of rape or incest up to second degree, in case of forced marriage, or if medically indicated. ¹¹ Yet, studies show that there is a need to have clarity and common understanding about the abortion law and its implementation among clinicians.^8,12 Access to abortion training affects overall access to healthcare services. A significant study collected anonymous online surveys from 1949 family physicians that completed their residency between 2010 and 2018. This study found that whether or not these clinicians received training on safe abortion and postabortion care influenced their likelihood of providing abortion services and the quality of care they offer. ¹³

Continuous training on abortion and postabortion care is needed among healthcare professionals to impact the level of knowledge and quality of abortion and postabortion care. Providers may refer to WHO and national guidelines for safe abortion when providing comprehensive abortion care services. Clinicians are key actors for the implementation of abortion law as well as delivering abortion and postabortion care. Studies have shown that those with adequate knowledge on abortion are more likely to practice safe abortion, yet gaps in abortion and postabortion care knowledge, attitudes, and practice have been identified among some healthcare professionals.^8,14

To the best of our knowledge, no study has been conducted in Rwanda looking at the effect of clinician training on abortion and postabortion care services. There is a need to explore the level of clinician’s knowledge of abortion and postabortion care in Rwanda. This study aimed to evaluate the effect of training on clinicians’ knowledge regarding abortion and postabortion care in six hospitals in Rwanda. While it seeks to enhance the understanding of clinical knowledge among doctors providing abortion and postabortion care services, it does not assess the adherence of these clinicians to national guidelines or the resulting implications for patient outcomes.

Methodology

Study design, population, and setting

We conducted a quasi-experimental study across six hospitals, teaching and nonteaching in Rwanda: Kibagabaga, Masaka, Kabutare, Muhima District Hospital, Rwamagana Provincial Hospital, and University Teaching Hospital of Kigali (CHUK). Kibagabaga, Masaka, Muhima, and CHUK hospitals are located in urban area and only Kabutare District Hospital was located in rural settings. All hospitals provide abortion and postabortion care services. CHUK, the largest tertiary teaching hospital located in Kigali, the capital of Rwanda, receives referred cases from district hospitals and has outpatient consultation. Being a teaching hospital, it remains an academic center where specialists, residents, general practitioners, and paramedic staff share knowledge daily. District hospitals being the secondary level of health facilities, receiving patients from health centers and are staffed with general medical doctors who provide essential healthcare services; are nonteaching hospitals, do not receive medical or postgraduate students in training and lack a detailed teaching plan on a daily basis among hospital staff. All six hospitals have busy maternity and provide abortion and postabortion care services.

For this study we used Taro Yamane’s formula for sample size calculation. ¹⁵ Again, with power of 0.80, effect size of 0.50, and alpha error probability of 0.05, we have computed with G*power and both yielded a sample size of 30 study participants. Medical doctors from study settings working in maternity were briefed on this study, and 30 medical doctors (male and female) across these six hospitals who meet the inclusion criteria were recruited to participate in this study. Participants signed a consent form on-site prior to enrollment in the study. Inclusion criteria required that participants had not previously attended training on abortion law and were actively providing abortion and postabortion care services at their hospital. Those who had attended similar training before, were unwilling to participate, or were not providing abortion and postabortion care services were excluded. Participants also confirmed they had not previously attended this type of training as a condition of enrollment. Additionally, hospital clinical directors helped identify eligible participants who had not undergone prior training but were providing abortion care services. Finally, we reviewed participants’ curricula vitae for further information before recruitment. The reporting of this study conforms to the JBI critical appraisal checklist for quasi-experiment studies. ¹⁶

Training

We trained 30 medical doctors from the above-mentioned hospitals, on abortion and postabortion care between April 2022 and June 2022, using most updated WHO^17,18 and Rwandan national guidelines on safe abortion. ¹⁹ All participants had university degree level, bachelor of medicine and surgery, and completed 1 year of internship at district hospitals before being licensed to practice in Rwanda as medical doctors. Four training sessions were conducted, each lasting 3 h. They covered different topics (see Annex 2), and included self-directed learning by participants using shared training materials. Training sessions were scheduled during evening after work where we could get maximum attendance of participants. All participants attended all training sessions. All training sessions were led by selected nationally recognized trainers, obstetricians, gynecologists, and consultant in forensic medicine with substantial experience with training physicians on abortion law in Rwanda, safe abortion, and postabortion care. A consultant in forensic medicine had experience in both the legal and clinical training of physicians on abortion care. His role in training physicians mainly focused on teaching the legal frameworks, regulations, and ethical considerations surrounding abortion. Knowledge-based training was delivered only by lecture. A pretest was conducted to assess participant knowledge on abortion and postabortion care before training, and follow-up posttest evaluation was conducted 3 months after the last training session. Marks below 60% were considered low, 61%–79% were considered good, and 80% and above were considered excellent. Pretest and posttest were coordinated and administered to clinicians by principal investigator (PI) of the research, after assembling all questions set by trainers, and PI was responsible of overseeing the training sessions progress.

Data collection and management

A form with survey questions was created by investigator, and participants were provided a Google link to respond to the survey questions (see Annex 1). Data were extracted from participants’ answer spreadsheets by trained research assistants and submitted to the PI to manage and analyze. Participants’ gender, affiliated hospital names and location, hospital status (teaching or nonteaching), pretest marks, and posttest marks were collected. This information was kept in a secured folder only accessible by research team members.

Statistical analyses

Pre- and posttest marks were calculated as score for each participant. Descriptive statistics were reported as percentage. Paired T-test was used to compare means of the score before and after intervention (training of clinicians) for participants using SPSS version 26, IBM Corporation, New York, United States.

Results

A total of 30 clinicians from 6 hospitals completed the study, 21 males (70%) and 9 females (30%), with mean age of 30.86 ± 5.79. Overall, after the training, the mean score of marks improved from 69.54 to 77.7 with p value <0.001.

Discussion

Our study aimed to assess the effect of training clinicians (medical doctors) in six hospitals in Rwanda on their knowledge of abortion and postabortion care in Rwanda. Overall, we found a statistically significant increase in marks between pretest and posttest, p value 0.001. This increase was statistically significant among trainees from hospitals (district and provincial hospitals) other than the teaching hospital (see Table 1). These findings show us that district and provincial hospitals had a room for improvement on their knowledge on abortion and postabortion care than teaching hospital. Teaching hospitals being academic and training centers have a bigger number of experts (especially clinical lecturers), including obstetrics and gynecology residents, who regularly spread knowledge to the clinical team who work in the same settings.

Table 1.

Pre- and posttest knowledge (mean score) by hospital affiliation type.

Hospital categories	n	Mean score (pretest)	St. dev	Mean score (posttest)	St. dev	t	p-Value: Paired t-test
Teaching hospital	5	72.8	15.8	76.3	16.1	−1.68 (−9.3, 2.3)	0.168
Provincial/District hospitals	25	68.82	8.9	78.01	9.0	−4.13 (−13.92, −4.62)	<0.001
Total	30	69.54	9	77.7	16.3	−4.31 (−12.17, 4.32 )	<0.001

We found an increase in marks between pretest and posttest. This increase was statistically significant among trainees from three hospitals: Kibagabaga, Muhima, and Kabutare (p value 0.046, p value <0.01, and p value <0.001, respectively; see Table 2). This increase in marks suggests that the training had a positive impact on clinicians’ knowledge that impacted their decision making and elaboration of management plan for abortion and postabortion care provision.

Table 2.

Pre- and posttest knowledge (mean score) by hospital affiliation of trainees.

Affiliated Hospitals	n	Mean score (pretest)	St. dev	Mean score (posttest)	St. dev	t	p Value: paired t-test
CHUK	5	72.80	13.1	76.30	15.5	−1.68 (−9.3, 2.3)	0.168
Kibagabaga	5	66.75	8.7	74.61	14.5	−3.28 (−15.6, −0.25)	0.046
Rwamagana	5	70.80	12	81.23	16.0	−1.73 (−27.1, 6.2)	0.158
Kabutare	5	65.10	7.9	79.31	15.7	−5.5 (−20.1, −8.4)	<0.001
Muhima	5	65	7.0	79	14.8	−4.0 (−19, 7)	<0.01
Masaka	5	77.75	15.1	74.35	13.9	0.75 (−10.8, 17.5)	0.506
Total	30	69.54	11.0	77.78	16.0	−4.31 (−12.17, 4.32)	<0.001

Improvement in knowledge has been observed in other settings. Studies in the United States and in Thailand have shown that training providers results in improved abortion knowledge after training.^20,21 One study carried out in Ethiopia evaluated knowledge, attitude, and practice of healthcare providers toward safe abortion provision in Addis Ababa health centers. Among 405 mid-level providers, 71.9% knew the definition of abortion in the Ethiopia context, but only 53.1% of respondents had adequate knowledge of safe abortion care. ¹⁴ 20.5% of these providers were trained on safe abortion, and among them, 81.9% were practicing/used to practice safe abortion services. ¹⁴ Having adequate knowledge on safe abortion impacted abortion and postabortion care services provision. ¹⁴

An increase in marks was also observed in Nigeria, Uganda, and Democratic Republic of Congo trainees following a workshop that piloted the uterine evacuation module, and this contributed to increasing participants’ theoretical knowledge and possibly technical and counseling skills. Moreover, participants reported improvement in their knowledge, practice, and improved confidence for safe abortion and postabortion care delivery after training. ²²

In a systematic review of pre- and postworkshop surveys from 43 abortion values clarification and attitude transformation (VCAT) workshops, conducted in 12 countries in Asia, Africa, and Latin America between 2006 and 2011, the overall mean knowledge score increased from 49.0 to 67.1(p < 0.001), out of a total score of 100, statistically significant improvement between the pre- and postworkshop survey. In-service training improved knowledge and skills on abortion. ²³

In our study, both male and female providers showed improvement in knowledge after the training (see Table 3). Studies using a sex/gender-sensitive model of training have highlighted that all elements of training, including trainee characteristics, the work environment, the training design, and training outcome are gendered. ²⁴ This means that being a female, or a male, may impact the training experience and therefore training outcomes. ²⁴ The results from our study show that safe abortion training impact both gender and should target both female and male clinicians. Improvement in knowledge may be achieved when training program address systemic barriers in providing abortion care, provide up-to-date clinical practice guidelines, and teach current laws governing abortion care and how they affect practice. ²⁵

Table 3.

Pre- and posttest knowledge (mean score) by gender of trainees.

Gender	n	Mean score (pretest)	St. dev	Mean score (posttest)	St. dev	t	p-Value: Paired t-test
Male clinician	21	70.38	14.0	77.57	16.1	−3.218 (−11.87, -2.47)	0.005
Female clinician	9	66.88	13	79.94	13.6	−5.32 (−18.71, -7.39)	0.001
Total	30	69.54	13.5	77.7	12.6	−4.31 (−12.17, 4.32)	<0.001

Our study did not ask about the training background of our participants (universities attended or prior in-service training). Our study’s findings are not generalizable to the rest of Rwanda or other in-service trainings. A strong point for our study is that we collected data from both male and female providers, and all received the same training and pre- and posttest evaluation.

Limitations

Our study focused only on the knowledge of abortion and postabortion care. To ensure positive health outcomes for patients, more research is needed to assess clinical competency and the practical skill level among clinicians who manage patients with abortion and postabortion care at teaching and nonteaching hospitals in Rwanda.

Conclusion

The findings from this study show that compared to pretest, abortion providers at district and provincial hospitals improved their knowledge score about abortion care, and this increase was statistically significant at three hospitals. Moreover, the statistically significant improvement was found among both male and female participating providers.

To ensure quality safe abortion care throughout the healthcare system, these findings suggest targeting primarily district hospitals with training. Moreover, the Rwandan Ministry of Health should direct limited resources for providing continuous training on abortion and postabortion care to clinicians attending nonteaching district hospitals.