Assessing the availability and readiness of health facilities to provide post-abortion care in Kenya: Results from a nationwide Health Facility Survey, 2023

Assessing the availability and readiness of health facilities to provide post-abortion care in Kenya: Results from a nationwide Health Facility Survey, 2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the availability and readiness of health facilities to provide post-abortion care in Kenya: Results from a nationwide Health Facility Survey, 2023 Kenneth Juma, Caitlin Rich, Esther Mutuku, Isaiah Akuku, Monica Giuffrida, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7305576/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Understanding a health system’s capacity to provide post-abortion care (PAC) offers crucial insights into the strengths, gaps, and weaknesses in delivering high-quality PAC services. In Kenya and elsewhere, inadequate data limits the ability of policy actors to prioritize critical interventions and investments for improving maternal healthcare. This study examined the capacity of health facilities in Kenya to provide PAC. Methods This paper uses data from a 2023 health facility survey conducted across a nationally representative sample of health facilities in Kenya to explore the capacity of health facilities to provide PAC. Data were collected on PAC signal function indicators, including the availability of services, equipment, supplies, and staffing over the last six months, and the readiness to provide PAC on the day of the survey. A descriptive analysis was conducted to estimate the proportion of facilities that meet the criteria for availability and readiness for each individual signal function definition and report these findings by facility level and ownership (public vs. private). Results Using the availability criteria, we estimate that 18.3% of primary-level health facilities meet the definition for basic PAC, and 24.1% of referral health facilities meet the definition for comprehensive PAC. These proportions drop when using the more stringent readiness definition (basic PAC for primary health facilities = 3.3%, comprehensive PAC for referral health facilities = 7.2%). The most significant drivers of reduced PAC availability and readiness include the inability to provide at least three types of short-acting contraceptives post-abortion, a lack of providers on-staff who are trained on PAC, and the inability to provide surgical operations among referral facilities. Conclusion Our findings confirm the need to enhance PAC services in Kenya by addressing the existing gaps in service provision. There is a need to pursue the full implementation of the PAC standards and assessment tools that streamline facility staffing, training, and supply of PAC commodities and equipment at all levels. Post-abortion care Abortion Health systems Capacity Quality of Post-abortion care Signal functions Figures Figure 1 Figure 2 Figure 3 Introduction Recent estimates suggest that approximately 2,380,000 pregnancies occur annually in Kenya, and 61% of these pregnancies are unintended [ 1 ]. Induced abortions are common in the country, with a 2023 study estimating an induced abortion incidence rate of 57.3 per 1,000 women of reproductive age (WRA) [ 2 ]. Despite its prevalence, abortion is largely restricted in Kenya and only permitted to save the health and life of a woman and in the case of rape [ 3 ]. In consequence, women struggle to access and receive safe abortion from formal health facilities and often resort to clandestine and unsafe methods and procedures that can result in severe and life-threatening complications [ 4 ]. Maternal morbidity and mortality are major public health concerns in Kenya. According to the 2019 national census data, the maternal mortality ratio is 355 per 100,000 live births [ 5 ]. In recent years, successive administrations of the Kenyan Government have made significant investments aimed at reducing maternal mortality, and a good deal of these efforts have been aimed at increasing access to contraceptive counseling services and contraceptive method provision to reduce unintended and unwanted pregnancies [ 6 ]. Such unintended pregnancies are often linked to adverse maternal health outcomes such as abortion-related morbidity and mortality. Despite the investment, the expected reduction in maternal deaths is yet to be realized and progress remains slow; a recent study of post-abortion care (PAC) patients found that 17.8% were classified as having potentially life-threatening complications (PLTCs) or severe maternal outcomes (SMOs) [ 2 ]. This is way higher than the 9.4% post-abortion patients with PLTCs and SMOs reported in a WHO multi-country survey on abortion complications across 11 sub-Saharan African (SSA) countries [ 7 ]. PAC is an emergency obstetric intervention provided to women who experience complications from unsafe or incomplete abortions. Despite PAC being an essential public health intervention that most countries, including Kenya, have committed to, a considerable proportion of women continue to be unable to access high-quality PAC within health facilities [ 8 ]. For instance, in 2012, approximately 30% of women who had induced abortions in Kenya and developed complications serious enough to require treatment were unable to receive the medical care they needed [ 9 ]. More recent studies have also revealed a high prevalence of repeat induced abortions and repeat unintended pregnancies in Kenya, which may be contributing to elevated rates of maternal morbidity and mortality [ 10 ]. These findings have raised questions as to the quality of post-abortion care that women receive in health facilities when they have abortions. Maternal morbidity and death from pregnancy loss can be linked to limitations in access to PAC, and expanding access to safe abortion and quality PAC could mitigate many of these negative health outcomes [ 11 , 12 ]. Nevertheless, several barriers impede timely access to PAC services, including legal restrictions on abortion, abortion-related stigma, behavior and negative attitudes of healthcare providers, low levels of awareness and knowledge of PAC services among women, and low capacity of health systems to provide quality PAC services [ 13 – 15 ]. In efforts to address abortion-related maternal morbidity and mortality in the country, researchers and stakeholders have focused on assessing access to quality and comprehensive PAC [ 8 , 11 , 14 , 16 ]. This is because understanding the capacity of the health system to deliver high-quality and comprehensive PAC services can highlight gaps between policy commitments and service provision, as well as identify areas that are amenable to cost-effective interventions, especially in the context of resource-limited settings. To this point, an analysis by Juma and colleagues in 2019 revealed considerable gaps and weaknesses in the delivery of basic and comprehensive PAC in Kenya, finding that only 6.3% of primary facilities had capacity for all basic PAC services, and less than half (42.9%) of referral-level facilities could deliver comprehensive PAC [ 17 ]. However, because of the sampling approach used in the study, it is possible that the study findings do not reflect the true capacity of the Kenyan health system to provide PAC nationally [ 17 ]. Moreover, there have been changes to the sexual and reproductive health and rights landscape in Kenya since the 2019 analysis that may have had an impact on the post-abortion service delivery environment. Focusing on the underlying policy environment, the High Court of Kenya reinstated the Standards and Guidelines for Reducing Morbidity & Mortality from Unsafe Abortion in Kenya in 2019, which had been withdrawn by the Ministry of Health [ 18 ]. The guidelines offered directions on PAC case management, training, supplies, commodities for PAC, and the monitoring and auditing of PAC. In 2022, the World Health Organization (WHO) released an updated abortion care guideline, which included recommendations on improving access to high-quality, person-centered abortion-related services [ 19 ]. It is unknown whether these updates in the abortion-related guidelines have resulted in improvements in post-abortion service delivery in Kenya. This study aimed to examine the capacity of the Kenyan health system to provide PAC by using the signal functions framework. Healy and colleagues [ 20 ] first developed the signal functions framework to measure the provision of abortion care services by adapting an existing United Nations-fronted model for monitoring the availability and use of Emergency Obstetric care (EmOC) services [ 21 ]. Since then, the signal function framework has been used to assess the capacity to provide safe abortion care (SAC) and PAC in several settings, including Ethiopia, Zambia [ 22 ], Ghana [ 23 ], Burkina Faso, Nigeria, and Kenya [ 17 ], and most recently Liberia [ 24 ]. Our analysis is the first to use the signal function framework with a nationally representative sample of health facilities in Kenya. The findings offer crucial insights into the availability and readiness of facilities to provide PAC services in the country. Methods Sampling and data collection Data for this analysis comes from the 2023 Kenya Health Facilities Survey (HFS). The HFS is a nationally representative survey of all health facilities in Kenya expected to provide post-abortion care. Our original sampling universe was supplied by the Ministry of Health in January 2023 and included 13,594 health facilities. Table 1 displays the sampling universe, sampling fractions, response rates, and final analytic sample for this study. The Kenyan health system is organized into six levels designated as: Level I facilities (community services), Level II (dispensaries and clinics), Level III (health centers, maternity and nursing homes), Level IV (sub-county hospitals, medium-sized private hospitals), Level V (county referral hospitals, large private hospitals), and Level VI (national referral and teaching hospitals, large private teaching hospitals). We stratified the facilities by region (Central and Nairobi, Coast and North Eastern, Eastern, Nyanza and Western, Rift Valley) and by facility Level (II-VI). Within each region, we selected 100% of Level V and VI, 50% of Level IV, 5% of Level III, and 2% of Level II facilities, resulting in a target sample of 694 facilities. Overall, our response rate was 94.4%. Reasons for non-response included inaccessibility for the interviewers due to insecurity, the facility was closed before the interviewer arrived at the facility, or access was declined by officials, resulting in a final sample of 658 facilities. To create nationally representative estimates of PAC capacity, we generated composite weights by multiplying the sampling weights with facility-level non-response weights. This approach allowed us to adjust appropriately for the complexities associated with our sampling design and the potential biases introduced by non-response. Table 1 Facility sample and response rate in Kenya Facility characteristics Universe Adjusted universe* Sampling fraction # Health facilities sampled Non-participating facilities Response rate (%) Final N Total 13,594 11,648 694 39 94.4% 658** Facility Level Level II 10544 8552 2% 133 8 94.0 125 Level III 2159 2308 5% 124 4 96.8 121** Level IV 830 721 50% 370 22 94.1 350** Level V 57 63 100% 63 4 93.7 59 Level VI 4 4 100% 4 1 75.0 3 *Adjusted after fielding to account for the number of facilities with potential capacity to provide PAC **Three facilities included in the final sample were purposely sampled While our sampling universe included facilities that are expected to provide PAC, 44 of the 658 sampled facilities reported that they did not offer any PAC services, representing an estimated 21% of all health facilities in Kenya (Appendix A). Almost all facilities that did not provide PAC were primary-level facilities[1] ; we estimate that 26.2% of all Level II facilities and a smaller proportion of Level III facilities (8.6%) did not offer PAC. Similar proportions of public and private for-profit facilities did not provide any PAC services (21.4% and 23.2%, respectively), whereas a smaller proportion of private non-profit facilities did not offer PAC (7.5%). For the signal functions analyses, we remove these facilities from the sample and estimate PAC capacity only among facilities that provide any of the PAC-related services, resulting in a final analytic sample of 614. At each facility, we aimed to interview a senior health provider who was knowledgeable about PAC provision and had been working there for at least six months. At large referral hospitals, respondents were mainly the heads of the obstetrics and gynecology departments or key obstetrician-gynecologists working in the facility. At lower-level facilities, a nurse, midwife, or other health worker knowledgeable about PAC services provided in the facility was interviewed. Trained enumerators conducted face-to-face interviews using a health facility survey questionnaire that included PAC signal function questions and recorded responses in an electronic form on the SurveyCTO platform through Android devices. The questionnaire had been adopted from previous studies conducted in Burkina Faso, Kenya, and Nigeria [ 17 ], and the tool captured the provision of PAC services, along with information on the availability of essential equipment and supplies, staff by cadre, training, and barriers to providing PAC (Supplementary material 1A). Completed and verified data were uploaded to a cloud server for safe storage. Measures To assess the capacity of Kenya’s health system to provide PAC, we adapted the signal functions framework, which was initially presented by Healy et al. [ 20 ] and further developed by Campbell et al. [ 22 ]. In brief, these signal functions cover curative and preventative services, as well as the personnel needed to perform them. This framework has been applied in several studies and countries over time, with exact definitions for each signal function varying by study based on data availability and context [ 17 , 23 – 34 ]. The signal functions framework assesses the capacity to provide basic and comprehensive PAC. In the context of Kenya, primary-level health facilities (Levels II and III) are expected to provide all basic emergency PAC services. Similarly, referral-level facilities (Levels IV, V, and VI) are expected to provide all the comprehensive PAC services [ 35 ]. Previous applications of the signal functions framework have primarily focused on providing key services over the past six months. However, by only focusing on general service provision, these definitions may obscure more acute barriers to providing PAC, such as commodity stock issues, short-term equipment functionality, and staff unavailability due to transfers, leave of absence, among other reasons. As such, this study adapts the definitions of capacity to provide PAC to include: 1) the availability of services, which focuses on whether a facility has provided each service in the past six months, and 2) the readiness to provide PAC, which incorporates additional information on equipment functionality and commodity stock-outs on the day of the survey interview. Table 2 presents the definitions of the availability and readiness signal functions used in this analysis. Table 2 Signal function definitions for the availability and readiness to provide postabortion care Service Signal Function Definition Readiness definition Availability definition Basic Parenteral antibiotics Provided in last 6 months + one type in-stock on day of data collection Uterotonics/oxytocics Provided in last 6 months + one type in-stock on day of data collection Intravenous fluids Provided in last 6 months + in-stock on day of data collection Removal of retained products of conception Provided at least 1 method* in last 6 moths + MVA/EVA kit available and functional AND/OR medication abortion (MA) pills in-stock on the day of data collection Services available in emergencies Facility operates 24/7 No additional requirements Staffing At least one person capable of providing postabortion care always on duty or on call + at least one provider registered with specialized training in postabortion care (ie. service integration, values clarification, patient sensitivity, etc.) Postabortion care family planning Offers one method in each of 3 categories: condoms, hormonal birth control pills, and injectables + at least one method in each category in-stock on day of data collection Family planning counseling and method provision available 24/7 No additional requirements Referral capacity Access to an ambulance or other vehicle for emergency transportation + vehicle is operational and fueled on day of data collection Comprehensive Long-acting reversable contraceptives Offers implants OR intrauterine devices + one type in-stock on day of data collection Blood transfusion Provided in last 6 months + blood products in stock on day of data collection Surgical capacity Provided in last 6 months + all necessary equipment available on day of data collection AND at least 1 anesthesiologist on staff *Methods include manual/electronic vacuum aspiration (MVA/EVA), dilation and evacuation (D&E), dilation and curettage (D&C), and medication abortion (misoprostol alone or in combination with mifepristone) Availability of PAC services To meet the criteria for availability of basic PAC, a facility must have offered the following services in the past six months: the provision of parenteral antibiotics, uterotonics/oxytocics, and intravenous fluids, as well as services that include at least one method for the removal of retained products of conception[2] . Due to the emergency nature of many post-abortion cases, PAC services must be offered on a 24/7 basis, and facilities must always have someone on duty or on call who can provide PAC. The availability of family planning is also considered an essential component of basic PAC, as it helps prevent the occurrence of unintended pregnancies, repeat abortions, and thereby, complications from induced abortions. As such, family planning counseling and commodity provision must also be available 24/7, and facilities must offer at least three short-acting reversible contraceptive methods (SARCs) with at least one type from each of the following categories: 1) barrier methods (male and/or female condoms), 2) hormonal birth control pills (inclusive of emergency contraceptive pills), and 3) injectables. Finally, to ensure that patients with more severe complications can be referred to higher-level facilities when necessary, facilities must have access to an ambulance or other vehicle for emergency transportation stationed at their own facility or attached to another facility. For the availability of comprehensive PAC (at Levels IV, V, and VI only), facilities must have provided all basic signal functions as well as blood transfusions and surgical procedures (i.e., laparotomy) in the past 6 months. Both blood transfusions and surgical procedures are needed for managing potentially life-threatening complications and severe maternal outcomes. Finally, facilities that meet the definition for comprehensive PAC must offer at least one type of long-acting reversible contraceptive (LARCs) (implants or intrauterine devices). Readiness to provide PAC For all medicines and contraceptive methods needed for basic and comprehensive PAC provision, we consider facilities ready to provide these services if they were available AND facilities had tracer items for each service in stock on the day of data collection. This includes parenteral antibiotics, uterotonics/oxytocics, intravenous fluids, SARCs, LARCs, and commodities needed for blood transfusions and surgical operations. For removal of retained products of conception, facilities must have a functional manual vacuum aspiration (MVA) kit available OR medication abortion (MA) pills in-stock on the day of data collection depending on which of these services was provided in the last 6 months. For staffing readiness, facilities need a PAC provider on duty or on call 24/7 and at least one provider registered (although not necessarily on duty) who has training in PAC. PAC training focuses on technical skills related to case management, pain management, family planning counseling, and paying attention to patient-centered needs, including communication and empathy, among others, which are necessary for ensuring high-quality PAC services. Finally, we considered a facility ready to refer patients in critical condition if they had an emergency vehicle that had fuel on the day of data collection. Statistical analysis First, we conduct a descriptive analysis to estimate the proportion of facilities that meet the criteria for availability and readiness each individual signal function definition (Appendix B). We then estimate the weighted proportion of all facilities in Kenya that meet the availability and readiness definitions for providing basic and comprehensive PAC. We do this overall, as well as by facility level and ownership (public vs. private). For both the availability and readiness definitions, primary-level facilities must have all basic signal functions to be classified as providing basic PAC, and referral-level facilities must have all comprehensive and basic signal functions to be considered as providing comprehensive PAC. To better understand the drivers of PAC capacity (or lack thereof), we conduct an iterative sensitivity test that drops each signal function indicator, one at a time, from the analysis and recalculates the weighted proportion that would meet the different capacity definitions. This allows us to understand whether any indicators are pointedly contributing to lower proportions of facilities that cannot provide basic and/or comprehensive PAC. All analyses were performed using Stata 17. Results Availability of basic and comprehensive PAC among primary and referral facilities Using the availability definition, we estimate that approximately 1 in 5 primary-level facilities in Kenya met the criteria for providing basic PAC in 2023 (18.3%) (Fig. 1 ). Among referral-level facilities, 24.1% met the definition for providing comprehensive PAC, and 25.1% met the definition for basic PAC. Notably, half of referral-level facilities (50.8%) could not meet the criteria for providing either basic or comprehensive PAC. As expected, PAC availability increased consistently by facility level; a larger proportion of Level III facilities meet the basic PAC criteria as compared to Level II facilities (31.4% vs. 13.9%), and the proportion of referral level facilities with comprehensive care availability increased by level, (Level IV = 21.5%; Level V = 51.7%; Level VI = 62.5%) (Appendix C). Figure 1 displays the results of our iterative sensitivity test where we re-estimated the proportion of facilities meeting the availability definition for basic and comprehensive care after dropping each signal function from the analysis. Among primary-level facilities, the largest driver of reduced basic PAC availability was 24/7 operating hours. After dropping this requirement from the definition, the proportion of primary-level facilities that met the definition for basic PAC availability increased by 9.2 percentage points (18.3–27.5%). The next largest contributor to low basic PAC availability was the provision of at least three SARCs. Dropping this requirement from the definition increased the proportion by 4.6 percentage points (18.3–22.9%). Among referral-level facilities, surgical capacity was the most significant driver of the reduced availability of comprehensive PAC. Excluding this signal function increased the proportion of facilities meeting the availability definition for comprehensive PAC from 24.1–39.3% (15.2 percentage points). The provision of at least three SARCs was similarly problematic for referral-level facilities; dropping this signal function increased comprehensive capacity by 7.6 percentage points (24.1–31.7%). Further, our analyses reveal that removing the SARC requirement would reduce the proportion of referral-level facilities that do not meet the criteria for having basic PAC availability by half (50.8–25.1%) (Fig. 2 ). Finally, if all referral-level facilities in Kenya met the availability definitions for surgical care and SARCs, more than half (53.6%) would have the capacity to provide comprehensive PAC. Readiness to provide basic and comprehensive PAC among primary and referral facilities We found that a considerably lower proportion of facilities in Kenya were ready to provide PAC on the day of the survey interview. The proportion of primary-level facilities that met the definition for readiness to provide basic PAC was 3.3% (Fig. 3 ), representing a 15percentage point decrease from the availability definition. A similar reduction was observed for the provision of comprehensive PAC among referral facilities with only 7.2% being ready to provide comprehensive PAC and 81.5% were not ready to provide even basic PAC. Once again, differences in readiness to provide PAC by facility level and ownership are provided in Appendix C. Of note, significant proportions of Level VI facilities (62.5%) met the definitions for readiness to provide comprehensive PAC compared to only 29.6% of Level V and 4.9% of Level IV. Figure 3 also displays the results of the iterative sensitivity tests for the readiness criteria. Similar to the availability results, readiness to provide at least three SARCs and surgical services like laparotomy (referral-level only) were the largest contributors to reduced PAC readiness. However, unlike the availability criteria, having the appropriate level of staffing also drives lower capacity; removing this signal function from the definition increased the proportion of primary-level facilities that met the definition for basic PAC from 3.3–11.5% (8.2 percentage points) and increased comprehensive PAC capacity among referral-level facilities by 4.8 percentage points (7.1–12.0%) Given that the inability to provide at least three SARCs on-site was one of the most consistent contributors to diminished PAC availability and readiness, we investigated why facilities could not provide this care (Appendix D). Overall, most facilities reported that they provide post-abortion care family planning counseling and services, but they failed to meet the signal functions requirement of offering a minimum of three types of short-acting contraceptive methods (referral-level: 62.2%, primary-level: 79.6%). Compared to primary-level facilities, referral-level facilities were more likely not to offer any contraceptive counseling (12.0% vs. 6.0%) and to not offer contraceptive methods on site (25.8% vs. 14.4%). Conversely, a larger proportion of primary-level facilities that did not meet the 3 + SARC criteria reported experiencing frequent stock-outs of contraceptive commodities as compared to referral-level facilities (64.1% vs. 54.8%, respectively). Discussion This paper presents the first-ever analysis comparing the availability and readiness of health facilities to provide PAC services among a nationally representative sample of health facilities in Kenya. As PAC is an obstetric intervention for abortion-related emergencies that women can experience at any given time, our measurement of both the availability of PAC over the past 6 months and the readiness to provide PAC on the day of data collection offer innovative and critical insight into existing health system gaps and weaknesses to provide PAC on any day and to all women who present at health facilities in Kenya. Overall, the study findings reveal sub-optimal availability to provide PAC across facility levels in Kenya. Fewer than 1 in 5 primary-level facilities (18.3%) met the criteria for availability of basic PAC in 2023, and only 24% of referral-level facilities met the definition of comprehensive PAC availability. These findings align with prior studies in SSA that used similar definitions of PAC capacity; a multi-country analysis in 10 low-income countries concluded that fewer than 10% of primary-level facilities could provide all elements of basic PAC [ 32 ], and similar results have been observed in more recent country-specific studies in Nigeria (9%), Burkina Faso (12%), Kenya (6%), Ethiopia (15%) and Uganda (18%) [ 17 , 28 ]. That said, Kenya’s basic PAC availability at primary-level facilities is substantially lower than findings in other countries such as Côte d’Ivoire (37.5%) and Senegal (53%) [ 32 ]. Our findings for comprehensive PAC availability are similar to those in Burkina Faso (30%), Senegal (32%), and Rwanda (33%) [ 17 , 32 ], but are lower than recent estimates for Tanzania (53%), and Malawi (58%) [ 32 ]. Notably, this study also estimates reduced comprehensive PAC capacity in Kenya compared to a previous 2019 study (43%) [ 17 ]. However, these differences are likely due to variations in the sampling strategies for the two studies and not a true reflection of lower comprehensive PAC availability in Kenya in 2023 as compared to 2019 [ 17 ].[3] The low availability of basic PAC among primary facilities in Kenya reflects a lack of prioritization and investment in PAC services at this facility level. This is problematic, as primary-level facilities are the first point of care for the vast majority of women who seek pregnancy-related services in their own communities. It is first important to note that about 21% of facilities overall, and approximately one-quarter (26.2%) of Level II facilities and 8.6% of Level III facilities sampled initially for this study, reported that they did not offer any PAC services at all. Further, among primary-level facilities that did report offering PAC, only 58% provided any services to remove retained products of conception (i.e., MVA, medication abortion, etc.) in the past six months. Because of this, women in need of PAC may resort to skip primary health facilities and go to higher-level facilities, resulting in crowding and delays to accessing care, even for life-threatening emergencies. Our iterative analysis did not identify this as a main driver of reduced PAC availability because other services were more commonly missing. However, given that the removal of retained products of conception is one of the most basic elements of PAC, this finding highlights another important gap in PAC service delivery in Kenya. Implementing the 2012 PAC standards and guidelines could help streamline service delivery and address these glaring gaps. For one, the inability to conduct removal of retained products of conception is largely due to the absence of trained providers, as well as unavailable or non-functional equipment and commodities. When providers are not trained, they lack the technical skills and confidence to deliver services. Our analysis showed that the most significant cause of the low availability of basic PAC was that many primary facilities do not operate on a 24/7 basis. Because PAC is often needed in emergency circumstances, women must always have ready access to care. However, in Kenya, most primary-level facilities cannot operate on a 24/7 basis due to the limited number of health personnel at these lower facility levels. This finding highlights one of the drawbacks of the signal functions; while having standard metrics allows for comparisons across countries over time, the signal functions approach does not account for geographic variability in both need and access to care. Policymakers are often forced to balance resource availability with the needs of the population they are serving, and it is not always necessary or strategic to ensure that 100% of primary-level facilities meet all criteria for basic PAC. For example, in facility-dense settings (such as high-population urban areas), it might not be necessary for all primary-level facilities to be open 24/7, as most women in need of PAC have reasonable access to nearby facilities with after-hours care. However, in rural communities, the closest referral-level facility that operates 24/7 may be hours away. Supporting Level II facilities in these settings to be open continuously might mean the difference between life and death. As such, combining geo-spatial analyses with the signal functions approach will likely provide more helpful guidance on how and where to allocate resources to improve access to PAC. Our results demonstrating that an inability to provide at least three short-acting reversible contraceptives was a significant driver of limited PAC availability across all facilities levels in Kenya points to an important missed opportunity in delivering high-quality PAC services in Kenya. Post-abortion family planning is a key component of PAC and is essential to provide women with options to prevent future unintended pregnancies. When women are not provided with sufficient contraceptive options to make choices that align with their reproductive desires and needs, it diminishes their autonomy and can lead to low uptake and/or discontinuation of contraceptive methods [ 36 ], as well as an increased risk of unintended pregnancy [ 10 ]. Only 64% of referral-level facilities met the criteria for providing three or more short-acting methods. This is likely due to policy and structural decisions by the management of higher-level health facilities who feel that it is more cost-effective to send women back to primary facilities for family planning services. The logic behind this policy is that women may be better served by accessing contraceptive care at a primary-level facility, leading to easier access to refills and higher continuation rates. However, providing contraceptive services in another entirely separate location often disrupts PAC services and creates room for patients to miss out on the service [ 37 ]. Our findings also suggest a need to strengthen supply chains for PAC supplies, including contraceptive commodities, and better integrate the delivery of contraceptive services in all facilities to improve their uptake and reduce missed opportunities. Among referral-level facilities in particular, another key impediment to comprehensive PAC availability was the limited capability to provide surgical operations. The ability to conduct abdominal surgeries is fundamental to the provision of comprehensive PAC and to manage some of the most life-threatening abortion complications. When referral-level facilities are unable to provide this function, it is almost not worth sending women to these facilities as this increases delays in access to life-saving care. There is a need to strengthen surgical capability among referral facilities, mainly by having appropriate equipment, commodities, and staff trained to perform laparatomies. Another important barrier to PAC readiness, was the lack of appropriately trained staff, the absence of which constrains service delivery and compromises the quality and safety of services. Without sufficient training, providers may offer poorer quality care, or avoid providing the service due to lack of confidence and refer patients to other facilities or providers, which can lead to delays. Several studies have affirmed the value of providers' receiving both pre-service and in-service training on clinical procedures to update the provider’s knowledge and technical competencies and align with best clinical practices and adoption of updated uterine evacuation technology, medications, and tools [ 8 , 16 , 38 ]. PAC training also provides an avenue to delivering social interventions such as value clarification and attitude transformation that address contextual barriers like stigma, improve patient-provider interactions, increase legal awareness, and enhance patient-centered care practices [ 39 ]. There is also the potential to provide training that supports provider mental health and reduce the stigma that has been previously reported in high-volume PAC facilities in Nigeria [ 40 ]. It is critical to note, however, that the training of providers does not guarantee the availability of trained providers in all health facilities eligible to provide PAC. Staff transfers, prolonged leaves of absence, and work shifts can mean that trained providers are not present at all facilities and during all operating hours, even though women experiencing complications can come for services at any given time. As demonstrated in the results of our study, this challenge highlights the need for both regular training of providers and for more than one trained provider to be available to provide PAC per health facility. These gaps in provider readiness could become even more pronounced in the current political environment, since most training programs are supported by non-governmental organizations that may be beneficiaries of US government funding. With the reinstatement of the Mexico City policy and other threats to sexual and reproductive health and rights-related services in the current political environment, it is critical that the Kenyan government and other stakeholders continue to ensure that PAC training remains widely available to providers across the country. Our analysis comparing the availability and readiness of PAC among health facilities offers critical insights on post-abortion care in Kenya. Overall, about 21% of health facilities, including one-quarter (26.2%) of Level II facilities and one-tenth (8.6%) of Level III facilities, reported that they did not offer any PAC services. As a result, some women seeking emergency care for their complications may not find that these critical services are available in their communities and may face delays in seeking and receiving care at the next point of delivery. Among all health facilities, the disparities between availability and readiness of basic and comprehensive PAC highlight severe and routine disruptions in the delivery of this emergency obstetrics service meant to avert deaths and long-term disabilities associated with abortion. Only 3.3% of primary-level facilities were ready to provide basic PAC, and only 7.2% of referral-level facilities were ready to provide comprehensive PAC. These proportions are 15% and 17% lower (respectively) than the corresponding proportions for availability, meaning that while facilities may have had the necessary PAC providers, equipment, and commodities over the last six months, availability of these critical components on a random day was often much more limited. Study strengths and limitations This is the first study that uses a nationally representative sample of facilities to assess the capacity of health facilities to provide PAC in the country. Including private facilities is particularly valuable because previous studies have exempted the private sector and thus failed to present a national picture of the state of PAC delivery in the country. Further, the researchers were able to combine assessment for both the PAC readiness and availability in the country. Nonetheless, our study is not without limitations. First, the signal functions framework is helpful to assess the overall capacity of a health system to provide PAC. However, without factoring in facility location clustering or geographic disparities in access to specific types of care, this approach may underestimate a health system’s true ability to provide PAC and/or obscure important care “deserts” within a country. Secondly, the signal functions framework only addresses structural capacity at the health-system level. While this is an important metric, it represents one of several aspects of quality of care. This paper does not provide insights of how PAC services were delivered, or the experiences and outcomes of women being treated within these facilities. As part of this study, the researchers did collect person-centered measures from a sample of women seeking PAC, even though the analysis of that dataset is not included in this paper. We recommend that future analysis integrate all the perspectives to describe the quality of PAC in Kenya and highlight additional areas where care can be improved. Finally, Kenya has a devolved governance system with 47 semi-autonomous counties, and health is one of the devolved sectors where counties have legal mandate to pursue strategic reforms. The study could not sample to account for all 47 counties and produce county-specific estimates, and this limits the level to which each administrative county can leverage the findings to address county-level gaps. Nevertheless, the study presents robust estimates for the regions (a cluster of counties), and the study team recommends that future studies attempt to ensure County-level estimates are possible. Conclusion Whereas public and primary-level health facilities bear the burden of addressing abortion-related complications in Kenya, a considerable proportion of these facilities did not have the capacity to offer the full complement of basic or comprehensive PAC. Similarly, patients arriving at referral-level facilities are not guaranteed to receive advanced care for their complications. These findings invite stronger advocacy to strengthen PAC by addressing the main drivers of gaps in availability and readiness to PAC: lack of surgical capacity, limited access to postabortion family planning services, and the absence of trained providers on-hand who are ready to address abortion-related needs. There is need to fully implement the PAC guidelines that streamline health provider staffing and training and the supply of PAC commodities and equipment. Abbreviations PAC Postabortion care WHO World Health Organization WRA Women of Reproductive Age SMO Severe Maternal Outcomes PLTCs Potentially Life-Threatening Complications SSA Sub-Saharan African EmOC Emergency Obstetric Care SAC Safe Abortion Care HFS Health Facilities Survey SARCs Short-Acting Reversible Contraceptive LARCs Long-Acting Reversible Contraceptive MVA manual vacuum aspiration D&E Dilation and Evacuation D&C Dilation and Curettage MA Medication Abortion Declarations Data availability statement Data are available upon reasonable request. De-identified data are available for future use when appropriate approvals are obtained. Ethics statements Patient consent for publication Not applicable. Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the AMREF Ethics and Scientific Research Committee (P1355/2022), the Kenyatta National Hospital-University of Nairobi Ethics Review Committee (P5/01/2023), Jaramogi Oginga Odinga Teaching and Referral Hospital-ISERC (ISERC/JOOTRH/703/23) and the Moi Teaching and Referral Hospital-Institutional Research and Ethics Committee (IREC/533/2023 - 0004474. A research permit was obtained from the National Commission of Science, Technology and Innovation (NACOSTI/P/24/35340). All study investigators completed a course on research ethics involving human subjects before engaging in the study. All participants provided written informed consent prior to participation. Contributors The corresponding author confirms that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. KJ, MG and YD conceived of the study and were awarded the grant funding. KJ, MG, YD, EM, SA, and IA, led the training and data collection. CR and EM assisted with data quality checks, and MG, OO, KJ and CR designed the analysis plan and CR completed data cleaning, management and conducted data analysis. All authors contributed to the interpretation of data and the writing of the manuscript. Funding This study was funded by the Hewlett Foundation (Grant #: 2022-01583-PRO) to the African Population and Health Research Center (APHRC), the Norwegian Agency for Development Cooperation (NADC) (Grant #: QZA-21/0135), and the Children's Investment Fund Foundation (CIFF) (Grant #: 2012-05769) to the Guttmacher Institute Disclaimer The views expressed are those of the author(s) and not necessarily those of the funders. Competing interests None declared. 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Assessing post-abortion care using the WHO quality of care framework for maternal and newborn health: a cross-sectional study in two African hospitals in humanitarian settings. Reprod Health. 2024;21: 114. doi:10.1186/s12978-024-01835-9 Juma K, Ouedraogo R, Amo-Adjei J, Sie A, Ouattara M, Emma-Echiegu N, et al. Health systems’ preparedness to provide post-abortion care: assessment of health facilities in Burkina Faso, Kenya and Nigeria. BMC Health Serv Res. 2022;22: 536. doi:10.1186/s12913-022-07873-y Ipas. Kenya restores standards and guidelines for comprehensive reproductive health, including abortion. Ipas Newsletter. 21 Jun 2019. Available: https://www.ipas.org/news/kenya-restores-standards-and-guidelines-for-comprehensive-reproductive-health-including-abortion/ Kim CR, Lavelanet A, Ganatra B. Enabling access to quality abortion care: WHO’s Abortion Care guideline. Lancet Glob Health. 2022;10: e467–e468. doi:10.1016/S2214-109X(21)00552-0 Healy J, Otsea K, Benson J. Counting abortions so that abortion counts: Indicators for monitoring the availability and use of abortion care services. Int J Gynecol Obstet. 2006;95: 209–220. doi:10.1016/j.ijgo.2006.08.002 Maine D, Wardlaw TM, Ward VM, McCarthy J, Birnbaum A, Akalin MZ, et al. Guidelines for monitoring the availability and use of obstetric services. 2nd. ed. UNICEF, WHO, UNFPA, editors. New York: United Nations Children’s Fund; 1997. Campbell OMR, Aquino EML, Vwalika B, Gabrysch S. Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia. BMC Pregnancy Childbirth. 2016;16: 105. doi:10.1186/s12884-016-0872-5 Owolabi O, Riley T, Otupiri E, Polis CB, Larsen-Reindorf R. The infrastructural capacity of Ghanaian health facilities to provide safe abortion and post-abortion care: a cross-sectional study. BMC Health Serv Res. 2021;21: 1104. doi:10.1186/s12913-021-07141-5 Koko Sr VS, Küng S, Doe CR, Candy N, Harmon-Gray W, Mutuku E, et al. Assessing facility capacity to provide safe abortion and post-abortion care in Liberia: a 2021 signal function survey across 48 public health facilities. BMC Public Health. 2025;25: 1702. doi:10.1186/s12889-025-22885-z Philbin J, Soeharno N, Giorgio M, Kurniawan R, Ingerick M, Utomo B. Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis. Reprod Health. 2020;17: 189. doi:10.1186/s12978-020-01033-3 Riley T, Madziyire MG, Owolabi O, Sully EA, Chipato T. Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities. BMC Health Serv Res. 2020;20: 244. doi:10.1186/s12913-020-05110-y McMahon HV, Karp C, Bell SO, Shiferaw S, Seme A, Yihdego M, et al. Availability of postabortion care services in Ethiopia: Estimates from a 2020 national sample of public facilities. Contracept X. 2022;4: 100087. doi:10.1016/j.conx.2022.100087 Stillman M, Kibira SPS, Shiferaw S, Makumbi F, Seme A, Sully EA, et al. Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda. BMC Health Serv Res. 2023;23: 104. doi:10.1186/s12913-022-09017-8 Magalona S, Thomas HL, Akilimali PZ, Kayembe D, Moreau C, Bell SO. Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC. BMC Health Serv Res. 2023;23: 658. doi:10.1186/s12913-023-09647-6 Thomas HL, Alzouma S, Oumarou S, Moreau C, Bell SO. Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data. BMC Health Serv Res. 2023;23: 1171. doi:10.1186/s12913-023-10107-4 Onadja Y, Compaoré R, Yugbaré DB, Thomas HL, Guiella G, Lougué S, et al. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res. 2024;24: 84. doi:10.1186/s12913-023-10538-z Owolabi OO, Biddlecom A, Whitehead HS. Health systems’ capacity to provide post-abortion care: a multicountry analysis using signal functions. Lancet Glob Health. 2019;7: e110–e118. doi:10.1016/S2214-109X(18)30404-2 Compaoré R, Mehrtash H, Calvert C, Qureshi Z, Bello FA, Baguiya A, et al. Health facilities’ capability to provide comprehensive postabortion care in Sub-Saharan Africa: Evidence from a cross-sectional survey across 210 high-volume facilities. Int J Gynecol Obstet. 2022;156: 7–19. doi:10.1002/ijgo.14056 Bell SO, Shankar M, Ahmed S, OlaOlorun F, Omoluabi E, Guiella G, et al. Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d’Ivoire. Health Policy Plan. 2021;36: 1077–1089. doi:10.1093/heapol/czab068 World Health Organization & Alliance for Health Policy and Systems Research. Primary health care systems (primasys): case study from Kenya: abridged version. Geneva: World Health Organization; 2017. Report No.: WHO/HIS/HSR/17.6. Available: https://iris.who.int/handle/10665/341073 Kungu W. Contraceptive use and discontinuation among women aged 15–24 years in Kenya. Front Reprod Health. 2023;5. doi:10.3389/frph.2023.1192193 Mwadhi MK, Bangha M, Wanjiru S, Mbuthia M, Kimemia G, Juma K, et al. Why do most young women not take up contraceptives after post-abortion care? An ethnographic study on the effectiveness and quality of contraceptive counselling after PAC in Kilifi County, Kenya. Sex Reprod Health Matters. 2023;31: 2264688. doi:10.1080/26410397.2023.2264688 Mainah J, Keraka M, Otieno D. Role of Nurses in the Uptake of Comprehensive Abortion Care in Tier Three Health Facilities in Nairobi County. 2018. Available: https://www.semanticscholar.org/paper/Role-of-Nurses-in-the-Uptake-of-Comprehensive-Care-Mainah-Keraka/dbe405c679118aeb63e0c759eec3e06344cbeadb Yegon E, Ominde J, Baynes C, Ngadaya E, Kahando R, Kahwa J, et al. The Quality of Postabortion Care in Tanzania: Service Provider Perspectives and Results From a Service Readiness Assessment. Glob Health Sci Pract. 2019;7: S315–S326. doi:10.9745/GHSP-D-19-00050 Okonofua F, Ntoimo L, Bury L, Bright S, Hoggart L. “When you provide abortion services, you are looked upon as a bad guy”: experiences of abortion stigma by health providers in Nigeria. Glob Health Action. 2024;17: 2401849. doi:10.1080/16549716.2024.2401849 Footnotes All Level V and Level IV facilities offered PAC. All but 1 Level IV facility in the sample provided PAC. Methods for the removal of retained products of conception include manual or electric vacuum aspiration (MVA/EVA), dilation and evacuation (D&E), dilation and curettage (D&C), or medication abortion (misoprostol alone or in combination with mifepristone). The 2019 study was not nationally representative as only seven counties out of the 47 were included. The sample size was also smaller and only had about 253 facilities compared to the 658 in this study. Additional Declarations No competing interests reported. Supplementary Files AppendixTablesandFigures.docx Supplementarymaterial1AHealthFacilitySignalFunctionsSurvey.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 05 Sep, 2025 Reviewers invited by journal 05 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Editor invited by journal 11 Aug, 2025 Submission checks completed at journal 10 Aug, 2025 First submitted to journal 10 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7305576","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512427832,"identity":"86849ddf-b1c5-460d-8079-b547285a844e","order_by":0,"name":"Kenneth Juma","email":"data:image/png;base64,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","orcid":"","institution":"African Population and Health Research Center","correspondingAuthor":true,"prefix":"","firstName":"Kenneth","middleName":"","lastName":"Juma","suffix":""},{"id":512427834,"identity":"26f1d122-6245-4f3d-bef9-cc8e05df80dc","order_by":1,"name":"Caitlin Rich","email":"","orcid":"","institution":"Guttmacher Institute","correspondingAuthor":false,"prefix":"","firstName":"Caitlin","middleName":"","lastName":"Rich","suffix":""},{"id":512427840,"identity":"2148f286-41c1-453d-9410-bf22962db3a4","order_by":2,"name":"Esther Mutuku","email":"","orcid":"","institution":"African Population and Health Research Center","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"","lastName":"Mutuku","suffix":""},{"id":512427849,"identity":"97e824df-ffca-4ec6-ab38-bcf2d1960059","order_by":3,"name":"Isaiah Akuku","email":"","orcid":"","institution":"African Population and Health Research Center","correspondingAuthor":false,"prefix":"","firstName":"Isaiah","middleName":"","lastName":"Akuku","suffix":""},{"id":512427850,"identity":"731a0bf1-2e10-4c12-b62d-03f9b312bcae","order_by":4,"name":"Monica Giuffrida","email":"","orcid":"","institution":"Guttmacher Institute","correspondingAuthor":false,"prefix":"","firstName":"Monica","middleName":"","lastName":"Giuffrida","suffix":""},{"id":512427851,"identity":"be252058-0632-4af9-88b9-58205f3da0d9","order_by":5,"name":"Sherine Athero","email":"","orcid":"","institution":"African Population and Health Research Center","correspondingAuthor":false,"prefix":"","firstName":"Sherine","middleName":"","lastName":"Athero","suffix":""},{"id":512427852,"identity":"6c6b34eb-832f-443f-a5f5-243a92c30319","order_by":6,"name":"Onikepe O. 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Induced abortions are common in the country, with a 2023 study estimating an induced abortion incidence rate of 57.3 per 1,000 women of reproductive age (WRA) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite its prevalence, abortion is largely restricted in Kenya and only permitted to save the health and life of a woman and in the case of rape [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In consequence, women struggle to access and receive safe abortion from formal health facilities and often resort to clandestine and unsafe methods and procedures that can result in severe and life-threatening complications [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMaternal morbidity and mortality are major public health concerns in Kenya. According to the 2019 national census data, the maternal mortality ratio is 355 per 100,000 live births [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In recent years, successive administrations of the Kenyan Government have made significant investments aimed at reducing maternal mortality, and a good deal of these efforts have been aimed at increasing access to contraceptive counseling services and contraceptive method provision to reduce unintended and unwanted pregnancies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Such unintended pregnancies are often linked to adverse maternal health outcomes such as abortion-related morbidity and mortality. Despite the investment, the expected reduction in maternal deaths is yet to be realized and progress remains slow; a recent study of post-abortion care (PAC) patients found that 17.8% were classified as having potentially life-threatening complications (PLTCs) or severe maternal outcomes (SMOs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This is way higher than the 9.4% post-abortion patients with PLTCs and SMOs reported in a WHO multi-country survey on abortion complications across 11 sub-Saharan African (SSA) countries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePAC is an emergency obstetric intervention provided to women who experience complications from unsafe or incomplete abortions. Despite PAC being an essential public health intervention that most countries, including Kenya, have committed to, a considerable proportion of women continue to be unable to access high-quality PAC within health facilities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For instance, in 2012, approximately 30% of women who had induced abortions in Kenya and developed complications serious enough to require treatment were unable to receive the medical care they needed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. More recent studies have also revealed a high prevalence of repeat induced abortions and repeat unintended pregnancies in Kenya, which may be contributing to elevated rates of maternal morbidity and mortality [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These findings have raised questions as to the quality of post-abortion care that women receive in health facilities when they have abortions. Maternal morbidity and death from pregnancy loss can be linked to limitations in access to PAC, and expanding access to safe abortion and quality PAC could mitigate many of these negative health outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Nevertheless, several barriers impede timely access to PAC services, including legal restrictions on abortion, abortion-related stigma, behavior and negative attitudes of healthcare providers, low levels of awareness and knowledge of PAC services among women, and low capacity of health systems to provide quality PAC services [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn efforts to address abortion-related maternal morbidity and mortality in the country, researchers and stakeholders have focused on assessing access to quality and comprehensive PAC [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is because understanding the capacity of the health system to deliver high-quality and comprehensive PAC services can highlight gaps between policy commitments and service provision, as well as identify areas that are amenable to cost-effective interventions, especially in the context of resource-limited settings. To this point, an analysis by Juma and colleagues in 2019 revealed considerable gaps and weaknesses in the delivery of basic and comprehensive PAC in Kenya, finding that only 6.3% of primary facilities had capacity for all basic PAC services, and less than half (42.9%) of referral-level facilities could deliver comprehensive PAC [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, because of the sampling approach used in the study, it is possible that the study findings do not reflect the true capacity of the Kenyan health system to provide PAC nationally [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, there have been changes to the sexual and reproductive health and rights landscape in Kenya since the 2019 analysis that may have had an impact on the post-abortion service delivery environment. Focusing on the underlying policy environment, the High Court of Kenya reinstated the \u003cem\u003eStandards and Guidelines for Reducing Morbidity \u0026amp; Mortality from Unsafe Abortion in Kenya\u003c/em\u003e in 2019, which had been withdrawn by the Ministry of Health [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The guidelines offered directions on PAC case management, training, supplies, commodities for PAC, and the monitoring and auditing of PAC. In 2022, the World Health Organization (WHO) released an updated abortion care guideline, which included recommendations on improving access to high-quality, person-centered abortion-related services [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It is unknown whether these updates in the abortion-related guidelines have resulted in improvements in post-abortion service delivery in Kenya.\u003c/p\u003e\u003cp\u003eThis study aimed to examine the capacity of the Kenyan health system to provide PAC by using the signal functions framework. Healy and colleagues [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] first developed the signal functions framework to measure the provision of abortion care services by adapting an existing United Nations-fronted model for monitoring the availability and use of Emergency Obstetric care (EmOC) services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Since then, the signal function framework has been used to assess the capacity to provide safe abortion care (SAC) and PAC in several settings, including Ethiopia, Zambia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Ghana [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Burkina Faso, Nigeria, and Kenya [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and most recently Liberia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our analysis is the first to use the signal function framework with a nationally representative sample of health facilities in Kenya. The findings offer crucial insights into the availability and readiness of facilities to provide PAC services in the country.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSampling and data collection\u003c/h2\u003e\u003cp\u003eData for this analysis comes from the 2023 Kenya Health Facilities Survey (HFS). The HFS is a nationally representative survey of all health facilities in Kenya expected to provide post-abortion care. Our original sampling universe was supplied by the Ministry of Health in January 2023 and included 13,594 health facilities. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the sampling universe, sampling fractions, response rates, and final analytic sample for this study. The Kenyan health system is organized into six levels designated as: Level I facilities (community services), Level II (dispensaries and clinics), Level III (health centers, maternity and nursing homes), Level IV (sub-county hospitals, medium-sized private hospitals), Level V (county referral hospitals, large private hospitals), and Level VI (national referral and teaching hospitals, large private teaching hospitals). We stratified the facilities by region (Central and Nairobi, Coast and North Eastern, Eastern, Nyanza and Western, Rift Valley) and by facility Level (II-VI). Within each region, we selected 100% of Level V and VI, 50% of Level IV, 5% of Level III, and 2% of Level II facilities, resulting in a target sample of 694 facilities. Overall, our response rate was 94.4%. Reasons for non-response included inaccessibility for the interviewers due to insecurity, the facility was closed before the interviewer arrived at the facility, or access was declined by officials, resulting in a final sample of 658 facilities. To create nationally representative estimates of PAC capacity, we generated composite weights by multiplying the sampling weights with facility-level non-response weights. This approach allowed us to adjust appropriately for the complexities associated with our sampling design and the potential biases introduced by non-response.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFacility sample and response rate in Kenya\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniverse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdjusted universe*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSampling fraction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e# Health facilities sampled\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNon-participating facilities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eResponse rate (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFinal N\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13,594\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11,648\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e694\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e94.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e658**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacility Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8552\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e94.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e96.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e121**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e830\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e370\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e94.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e350**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel V\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e93.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevel VI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Adjusted after fielding to account for the number of facilities with potential capacity to provide PAC\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e**Three facilities included in the final sample were purposely sampled\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile our sampling universe included facilities that are expected to provide PAC, 44 of the 658 sampled facilities reported that they did not offer any PAC services, representing an estimated 21% of all health facilities in Kenya (Appendix A). Almost all facilities that did not provide PAC were primary-level facilities[1]\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e; we estimate that 26.2% of all Level II facilities and a smaller proportion of Level III facilities (8.6%) did not offer PAC. Similar proportions of public and private for-profit facilities did not provide any PAC services (21.4% and 23.2%, respectively), whereas a smaller proportion of private non-profit facilities did not offer PAC (7.5%). For the signal functions analyses, we remove these facilities from the sample and estimate PAC capacity only among facilities that provide any of the PAC-related services, resulting in a final analytic sample of 614.\u003c/p\u003e\u003cp\u003eAt each facility, we aimed to interview a senior health provider who was knowledgeable about PAC provision and had been working there for at least six months. At large referral hospitals, respondents were mainly the heads of the obstetrics and gynecology departments or key obstetrician-gynecologists working in the facility. At lower-level facilities, a nurse, midwife, or other health worker knowledgeable about PAC services provided in the facility was interviewed. Trained enumerators conducted face-to-face interviews using a health facility survey questionnaire that included PAC signal function questions and recorded responses in an electronic form on the SurveyCTO platform through Android devices. The questionnaire had been adopted from previous studies conducted in Burkina Faso, Kenya, and Nigeria [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and the tool captured the provision of PAC services, along with information on the availability of essential equipment and supplies, staff by cadre, training, and barriers to providing PAC (Supplementary material 1A). Completed and verified data were uploaded to a cloud server for safe storage.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eTo assess the capacity of Kenya\u0026rsquo;s health system to provide PAC, we adapted the signal functions framework, which was initially presented by Healy et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and further developed by Campbell et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In brief, these signal functions cover curative and preventative services, as well as the personnel needed to perform them. This framework has been applied in several studies and countries over time, with exact definitions for each signal function varying by study based on data availability and context [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The signal functions framework assesses the capacity to provide \u003cem\u003ebasic\u003c/em\u003e and \u003cem\u003ecomprehensive\u003c/em\u003e PAC. In the context of Kenya, primary-level health facilities (Levels II and III) are expected to provide all basic emergency PAC services. Similarly, referral-level facilities (Levels IV, V, and VI) are expected to provide all the comprehensive PAC services [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious applications of the signal functions framework have primarily focused on providing key services over the past six months. However, by only focusing on general service provision, these definitions may obscure more acute barriers to providing PAC, such as commodity stock issues, short-term equipment functionality, and staff unavailability due to transfers, leave of absence, among other reasons. As such, this study adapts the definitions of capacity to provide PAC to include: 1) the \u003cem\u003eavailability\u003c/em\u003e of services, which focuses on whether a facility has provided each service in the past six months, and 2) the \u003cem\u003ereadiness\u003c/em\u003e to provide PAC, which incorporates additional information on equipment functionality and commodity stock-outs on the day of the survey interview. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the definitions of the availability and readiness signal functions used in this analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSignal function definitions for the availability and readiness to provide postabortion care\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eService\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eSignal Function Definition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReadiness definition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAvailability definition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eBasic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParenteral antibiotics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided in last 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ one type in-stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUterotonics/oxytocics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided in last 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ one type in-stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntravenous fluids\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided in last 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ in-stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRemoval of retained products of conception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided at least 1 method* in last 6 moths\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ MVA/EVA kit available and functional AND/OR medication abortion (MA) pills in-stock on the day of data collection\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eServices available in emergencies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFacility operates 24/7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo additional requirements\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStaffing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAt least one person capable of providing postabortion care always on duty or on call\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ at least one provider registered with specialized training in postabortion care (ie. service integration, values clarification, patient sensitivity, etc.)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePostabortion care family planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOffers one method in each of 3 categories: condoms, hormonal birth control pills, and injectables\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ at least one method in each category in-stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFamily planning counseling and method provision available 24/7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo additional requirements\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReferral capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAccess to an ambulance or other vehicle for emergency transportation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ vehicle is operational and fueled on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eComprehensive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLong-acting reversable contraceptives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOffers implants OR intrauterine devices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ one type in-stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlood transfusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided in last 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ blood products in stock on day of data collection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSurgical capacity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvided in last 6 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e+ all necessary equipment available on day of data collection AND at least 1 anesthesiologist on staff\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Methods include manual/electronic vacuum aspiration (MVA/EVA), dilation and evacuation (D\u0026amp;E), dilation and curettage (D\u0026amp;C), and medication abortion (misoprostol alone or in combination with mifepristone)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eAvailability of PAC services\u003c/h3\u003e\n\u003cp\u003eTo meet the criteria for \u003cem\u003eavailability\u003c/em\u003e of basic PAC, a facility must have offered the following services in the past six months: the provision of parenteral antibiotics, uterotonics/oxytocics, and intravenous fluids, as well as services that include at least one method for the removal of retained products of conception[2]\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e. Due to the emergency nature of many post-abortion cases, PAC services must be offered on a 24/7 basis, and facilities must always have someone on duty or on call who can provide PAC. The availability of family planning is also considered an essential component of basic PAC, as it helps prevent the occurrence of unintended pregnancies, repeat abortions, and thereby, complications from induced abortions. As such, family planning counseling and commodity provision must also be available 24/7, and facilities must offer at least three short-acting reversible contraceptive methods (SARCs) with at least one type from each of the following categories: 1) barrier methods (male and/or female condoms), 2) hormonal birth control pills (inclusive of emergency contraceptive pills), and 3) injectables. Finally, to ensure that patients with more severe complications can be referred to higher-level facilities when necessary, facilities must have access to an ambulance or other vehicle for emergency transportation stationed at their own facility or attached to another facility.\u003c/p\u003e\u003cp\u003eFor the \u003cem\u003eavailability\u003c/em\u003e of comprehensive PAC (at Levels IV, V, and VI only), facilities must have provided all basic signal functions as well as blood transfusions and surgical procedures (i.e., laparotomy) in the past 6 months. Both blood transfusions and surgical procedures are needed for managing potentially life-threatening complications and severe maternal outcomes. Finally, facilities that meet the definition for comprehensive PAC must offer at least one type of long-acting reversible contraceptive (LARCs) (implants or intrauterine devices).\u003c/p\u003e\n\u003ch3\u003eReadiness to provide PAC\u003c/h3\u003e\n\u003cp\u003eFor all medicines and contraceptive methods needed for basic and comprehensive PAC provision, we consider facilities \u003cem\u003eready\u003c/em\u003e to provide these services if they were available AND facilities had tracer items for each service in stock on the day of data collection. This includes parenteral antibiotics, uterotonics/oxytocics, intravenous fluids, SARCs, LARCs, and commodities needed for blood transfusions and surgical operations. For removal of retained products of conception, facilities must have a functional manual vacuum aspiration (MVA) kit available OR medication abortion (MA) pills in-stock on the day of data collection depending on which of these services was provided in the last 6 months. For staffing readiness, facilities need a PAC provider on duty or on call 24/7 and at least one provider registered (although not necessarily on duty) who has training in PAC. PAC training focuses on technical skills related to case management, pain management, family planning counseling, and paying attention to patient-centered needs, including communication and empathy, among others, which are necessary for ensuring high-quality PAC services. Finally, we considered a facility ready to refer patients in critical condition if they had an emergency vehicle that had fuel on the day of data collection.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eFirst, we conduct a descriptive analysis to estimate the proportion of facilities that meet the criteria for availability and readiness each individual signal function definition (Appendix B). We then estimate the weighted proportion of all facilities in Kenya that meet the availability and readiness definitions for providing basic and comprehensive PAC. We do this overall, as well as by facility level and ownership (public vs. private). For both the availability and readiness definitions, primary-level facilities must have all basic signal functions to be classified as providing basic PAC, and referral-level facilities must have all comprehensive and basic signal functions to be considered as providing comprehensive PAC.\u003c/p\u003e\u003cp\u003eTo better understand the drivers of PAC capacity (or lack thereof), we conduct an iterative sensitivity test that drops each signal function indicator, one at a time, from the analysis and recalculates the weighted proportion that would meet the different capacity definitions. This allows us to understand whether any indicators are pointedly contributing to lower proportions of facilities that cannot provide basic and/or comprehensive PAC. All analyses were performed using Stata 17.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eAvailability of basic and comprehensive PAC among primary and referral facilities\u003c/h2\u003e\u003cp\u003eUsing the availability definition, we estimate that approximately 1 in 5 primary-level facilities in Kenya met the criteria for providing basic PAC in 2023 (18.3%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among referral-level facilities, 24.1% met the definition for providing comprehensive PAC, and 25.1% met the definition for basic PAC. Notably, half of referral-level facilities (50.8%) could not meet the criteria for providing either basic or comprehensive PAC. As expected, PAC availability increased consistently by facility level; a larger proportion of Level III facilities meet the basic PAC criteria as compared to Level II facilities (31.4% vs. 13.9%), and the proportion of referral level facilities with comprehensive care availability increased by level, (Level IV\u0026thinsp;=\u0026thinsp;21.5%; Level V\u0026thinsp;=\u0026thinsp;51.7%; Level VI\u0026thinsp;=\u0026thinsp;62.5%) (Appendix C).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the results of our iterative sensitivity test where we re-estimated the proportion of facilities meeting the availability definition for basic and comprehensive care after dropping each signal function from the analysis. Among primary-level facilities, the largest driver of reduced basic PAC availability was 24/7 operating hours. After dropping this requirement from the definition, the proportion of primary-level facilities that met the definition for basic PAC availability increased by 9.2 percentage points (18.3\u0026ndash;27.5%). The next largest contributor to low basic PAC availability was the provision of at least three SARCs. Dropping this requirement from the definition increased the proportion by 4.6 percentage points (18.3\u0026ndash;22.9%). Among referral-level facilities, surgical capacity was the most significant driver of the reduced availability of comprehensive PAC. Excluding this signal function increased the proportion of facilities meeting the availability definition for comprehensive PAC from 24.1\u0026ndash;39.3% (15.2 percentage points).\u003c/p\u003e\u003cp\u003eThe provision of at least three SARCs was similarly problematic for referral-level facilities; dropping this signal function increased comprehensive capacity by 7.6 percentage points (24.1\u0026ndash;31.7%). Further, our analyses reveal that removing the SARC requirement would reduce the proportion of referral-level facilities that do not meet the criteria for having \u003cem\u003ebasic\u003c/em\u003e PAC availability by half (50.8\u0026ndash;25.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Finally, if all referral-level facilities in Kenya met the availability definitions for surgical care and SARCs, more than half (53.6%) would have the capacity to provide comprehensive PAC.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReadiness to provide basic and comprehensive PAC among primary and referral facilities\u003c/h3\u003e\n\u003cp\u003eWe found that a considerably lower proportion of facilities in Kenya were ready to provide PAC on the day of the survey interview. The proportion of primary-level facilities that met the definition for readiness to provide basic PAC was 3.3% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), representing a 15percentage point decrease from the availability definition. A similar reduction was observed for the provision of comprehensive PAC among referral facilities with only 7.2% being ready to provide comprehensive PAC and 81.5% were not ready to provide even basic PAC. Once again, differences in readiness to provide PAC by facility level and ownership are provided in Appendix C. Of note, significant proportions of Level VI facilities (62.5%) met the definitions for readiness to provide comprehensive PAC compared to only 29.6% of Level V and 4.9% of Level IV.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e also displays the results of the iterative sensitivity tests for the readiness criteria. Similar to the availability results, readiness to provide at least three SARCs and surgical services like laparotomy (referral-level only) were the largest contributors to reduced PAC readiness. However, unlike the availability criteria, having the appropriate level of staffing also drives lower capacity; removing this signal function from the definition increased the proportion of primary-level facilities that met the definition for basic PAC from 3.3\u0026ndash;11.5% (8.2 percentage points) and increased comprehensive PAC capacity among referral-level facilities by 4.8 percentage points (7.1\u0026ndash;12.0%)\u003c/p\u003e\u003cp\u003eGiven that the inability to provide at least three SARCs on-site was one of the most consistent contributors to diminished PAC availability and readiness, we investigated why facilities could not provide this care (Appendix D). Overall, most facilities reported that they provide post-abortion care family planning counseling and services, but they failed to meet the signal functions requirement of offering a minimum of three types of short-acting contraceptive methods (referral-level: 62.2%, primary-level: 79.6%). Compared to primary-level facilities, referral-level facilities were more likely not to offer any contraceptive counseling (12.0% vs. 6.0%) and to not offer contraceptive methods on site (25.8% vs. 14.4%). Conversely, a larger proportion of primary-level facilities that did not meet the 3\u0026thinsp;+\u0026thinsp;SARC criteria reported experiencing frequent stock-outs of contraceptive commodities as compared to referral-level facilities (64.1% vs. 54.8%, respectively).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper presents the first-ever analysis comparing the availability and readiness of health facilities to provide PAC services among a nationally representative sample of health facilities in Kenya. As PAC is an obstetric intervention for abortion-related emergencies that women can experience at any given time, our measurement of both the availability of PAC over the past 6 months and the readiness to provide PAC on the day of data collection offer innovative and critical insight into existing health system gaps and weaknesses to provide PAC on any day and to all women who present at health facilities in Kenya.\u003c/p\u003e\u003cp\u003eOverall, the study findings reveal sub-optimal availability to provide PAC across facility levels in Kenya. Fewer than 1 in 5 primary-level facilities (18.3%) met the criteria for availability of basic PAC in 2023, and only 24% of referral-level facilities met the definition of comprehensive PAC availability. These findings align with prior studies in SSA that used similar definitions of PAC capacity; a multi-country analysis in 10 low-income countries concluded that fewer than 10% of primary-level facilities could provide all elements of basic PAC [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and similar results have been observed in more recent country-specific studies in Nigeria (9%), Burkina Faso (12%), Kenya (6%), Ethiopia (15%) and Uganda (18%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. That said, Kenya\u0026rsquo;s basic PAC availability at primary-level facilities is substantially lower than findings in other countries such as C\u0026ocirc;te d\u0026rsquo;Ivoire (37.5%) and Senegal (53%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Our findings for comprehensive PAC availability are similar to those in Burkina Faso (30%), Senegal (32%), and Rwanda (33%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], but are lower than recent estimates for Tanzania (53%), and Malawi (58%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Notably, this study also estimates reduced comprehensive PAC capacity in Kenya compared to a previous 2019 study (43%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, these differences are likely due to variations in the sampling strategies for the two studies and not a true reflection of lower comprehensive PAC availability in Kenya in 2023 as compared to 2019 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].[3]\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e\u003c/p\u003e\u003cp\u003eThe low availability of basic PAC among primary facilities in Kenya reflects a lack of prioritization and investment in PAC services at this facility level. This is problematic, as primary-level facilities are the first point of care for the vast majority of women who seek pregnancy-related services in their own communities. It is first important to note that about 21% of facilities overall, and approximately one-quarter (26.2%) of Level II facilities and 8.6% of Level III facilities sampled initially for this study, reported that they did not offer any PAC services at all. Further, among primary-level facilities that did report offering PAC, only 58% provided any services to remove retained products of conception (i.e., MVA, medication abortion, etc.) in the past six months. Because of this, women in need of PAC may resort to skip primary health facilities and go to higher-level facilities, resulting in crowding and delays to accessing care, even for life-threatening emergencies. Our iterative analysis did not identify this as a main driver of reduced PAC availability because other services were more commonly missing. However, given that the removal of retained products of conception is one of the most basic elements of PAC, this finding highlights another important gap in PAC service delivery in Kenya. Implementing the 2012 PAC standards and guidelines could help streamline service delivery and address these glaring gaps. For one, the inability to conduct removal of retained products of conception is largely due to the absence of trained providers, as well as unavailable or non-functional equipment and commodities. When providers are not trained, they lack the technical skills and confidence to deliver services.\u003c/p\u003e\u003cp\u003eOur analysis showed that the most significant cause of the low availability of basic PAC was that many primary facilities do not operate on a 24/7 basis. Because PAC is often needed in emergency circumstances, women must always have ready access to care. However, in Kenya, most primary-level facilities cannot operate on a 24/7 basis due to the limited number of health personnel at these lower facility levels. This finding highlights one of the drawbacks of the signal functions; while having standard metrics allows for comparisons across countries over time, the signal functions approach does not account for geographic variability in both need and access to care. Policymakers are often forced to balance resource availability with the needs of the population they are serving, and it is not always necessary or strategic to ensure that 100% of primary-level facilities meet all criteria for basic PAC. For example, in facility-dense settings (such as high-population urban areas), it might not be necessary for all primary-level facilities to be open 24/7, as most women in need of PAC have reasonable access to nearby facilities with after-hours care. However, in rural communities, the closest referral-level facility that operates 24/7 may be hours away. Supporting Level II facilities in these settings to be open continuously might mean the difference between life and death. As such, combining geo-spatial analyses with the signal functions approach will likely provide more helpful guidance on how and where to allocate resources to improve access to PAC.\u003c/p\u003e\u003cp\u003eOur results demonstrating that an inability to provide at least three short-acting reversible contraceptives was a significant driver of limited PAC availability across all facilities levels in Kenya points to an important missed opportunity in delivering high-quality PAC services in Kenya. Post-abortion family planning is a key component of PAC and is essential to provide women with options to prevent future unintended pregnancies. When women are not provided with sufficient contraceptive options to make choices that align with their reproductive desires and needs, it diminishes their autonomy and can lead to low uptake and/or discontinuation of contraceptive methods [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], as well as an increased risk of unintended pregnancy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Only 64% of referral-level facilities met the criteria for providing three or more short-acting methods. This is likely due to policy and structural decisions by the management of higher-level health facilities who feel that it is more cost-effective to send women back to primary facilities for family planning services. The logic behind this policy is that women may be better served by accessing contraceptive care at a primary-level facility, leading to easier access to refills and higher continuation rates. However, providing contraceptive services in another entirely separate location often disrupts PAC services and creates room for patients to miss out on the service [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our findings also suggest a need to strengthen supply chains for PAC supplies, including contraceptive commodities, and better integrate the delivery of contraceptive services in all facilities to improve their uptake and reduce missed opportunities.\u003c/p\u003e\u003cp\u003eAmong referral-level facilities in particular, another key impediment to comprehensive PAC availability was the limited capability to provide surgical operations. The ability to conduct abdominal surgeries is fundamental to the provision of comprehensive PAC and to manage some of the most life-threatening abortion complications. When referral-level facilities are unable to provide this function, it is almost not worth sending women to these facilities as this increases delays in access to life-saving care. There is a need to strengthen surgical capability among referral facilities, mainly by having appropriate equipment, commodities, and staff trained to perform laparatomies.\u003c/p\u003e\u003cp\u003eAnother important barrier to PAC readiness, was the lack of appropriately trained staff, the absence of which constrains service delivery and compromises the quality and safety of services. Without sufficient training, providers may offer poorer quality care, or avoid providing the service due to lack of confidence and refer patients to other facilities or providers, which can lead to delays. Several studies have affirmed the value of providers' receiving both pre-service and in-service training on clinical procedures to update the provider\u0026rsquo;s knowledge and technical competencies and align with best clinical practices and adoption of updated uterine evacuation technology, medications, and tools [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. PAC training also provides an avenue to delivering social interventions such as value clarification and attitude transformation that address contextual barriers like stigma, improve patient-provider interactions, increase legal awareness, and enhance patient-centered care practices [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. There is also the potential to provide training that supports provider mental health and reduce the stigma that has been previously reported in high-volume PAC facilities in Nigeria [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. It is critical to note, however, that the training of providers does not guarantee the availability of trained providers in all health facilities eligible to provide PAC. Staff transfers, prolonged leaves of absence, and work shifts can mean that trained providers are not present at all facilities and during all operating hours, even though women experiencing complications can come for services at any given time. As demonstrated in the results of our study, this challenge highlights the need for both regular training of providers and for more than one trained provider to be available to provide PAC per health facility. These gaps in provider readiness could become even more pronounced in the current political environment, since most training programs are supported by non-governmental organizations that may be beneficiaries of US government funding. With the reinstatement of the Mexico City policy and other threats to sexual and reproductive health and rights-related services in the current political environment, it is critical that the Kenyan government and other stakeholders continue to ensure that PAC training remains widely available to providers across the country.\u003c/p\u003e\u003cp\u003eOur analysis comparing the availability and readiness of PAC among health facilities offers critical insights on post-abortion care in Kenya. Overall, about 21% of health facilities, including one-quarter (26.2%) of Level II facilities and one-tenth (8.6%) of Level III facilities, reported that they did not offer any PAC services. As a result, some women seeking emergency care for their complications may not find that these critical services are available in their communities and may face delays in seeking and receiving care at the next point of delivery. Among all health facilities, the disparities between availability and readiness of basic and comprehensive PAC highlight severe and routine disruptions in the delivery of this emergency obstetrics service meant to avert deaths and long-term disabilities associated with abortion. Only 3.3% of primary-level facilities were ready to provide basic PAC, and only 7.2% of referral-level facilities were ready to provide comprehensive PAC. These proportions are 15% and 17% lower (respectively) than the corresponding proportions for availability, meaning that while facilities may have had the necessary PAC providers, equipment, and commodities over the last six months, availability of these critical components on a random day was often much more limited.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e\u003cp\u003eThis is the first study that uses a nationally representative sample of facilities to assess the capacity of health facilities to provide PAC in the country. Including private facilities is particularly valuable because previous studies have exempted the private sector and thus failed to present a national picture of the state of PAC delivery in the country. Further, the researchers were able to combine assessment for both the PAC readiness and availability in the country.\u003c/p\u003e\u003cp\u003eNonetheless, our study is not without limitations. First, the signal functions framework is helpful to assess the overall capacity of a health system to provide PAC. However, without factoring in facility location clustering or geographic disparities in access to specific types of care, this approach may underestimate a health system\u0026rsquo;s true ability to provide PAC and/or obscure important care \u0026ldquo;deserts\u0026rdquo; within a country. Secondly, the signal functions framework only addresses structural capacity at the health-system level. While this is an important metric, it represents one of several aspects of quality of care. This paper does not provide insights of how PAC services were delivered, or the experiences and outcomes of women being treated within these facilities. As part of this study, the researchers did collect person-centered measures from a sample of women seeking PAC, even though the analysis of that dataset is not included in this paper. We recommend that future analysis integrate all the perspectives to describe the quality of PAC in Kenya and highlight additional areas where care can be improved. Finally, Kenya has a devolved governance system with 47 semi-autonomous counties, and health is one of the devolved sectors where counties have legal mandate to pursue strategic reforms. The study could not sample to account for all 47 counties and produce county-specific estimates, and this limits the level to which each administrative county can leverage the findings to address county-level gaps. Nevertheless, the study presents robust estimates for the regions (a cluster of counties), and the study team recommends that future studies attempt to ensure County-level estimates are possible.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhereas public and primary-level health facilities bear the burden of addressing abortion-related complications in Kenya, a considerable proportion of these facilities did not have the capacity to offer the full complement of basic or comprehensive PAC. Similarly, patients arriving at referral-level facilities are not guaranteed to receive advanced care for their complications. These findings invite stronger advocacy to strengthen PAC by addressing the main drivers of gaps in availability and readiness to PAC: lack of surgical capacity, limited access to postabortion family planning services, and the absence of trained providers on-hand who are ready to address abortion-related needs. There is need to fully implement the PAC guidelines that streamline health provider staffing and training and the supply of PAC commodities and equipment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003ePAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePostabortion care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eWRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eWomen of Reproductive Age\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eSMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSevere Maternal Outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003ePLTCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003ePotentially Life-Threatening Complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSub-Saharan African\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEmOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eEmergency Obstetric Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eSAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eSafe Abortion Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eHFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eHealth Facilities Survey\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eSARCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eShort-Acting Reversible Contraceptive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eLARCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eLong-Acting Reversible Contraceptive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eMVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003emanual vacuum aspiration\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eD\u0026amp;E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eDilation and Evacuation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eD\u0026amp;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eDilation and Curettage\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 288px;\"\u003e\n \u003cp\u003eMedication Abortion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request. De-identified data are available for future use when appropriate approvals are obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatient consent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the AMREF Ethics and Scientific Research Committee (P1355/2022), the Kenyatta National Hospital-University of Nairobi Ethics Review Committee (P5/01/2023), Jaramogi Oginga Odinga Teaching and Referral Hospital-ISERC (ISERC/JOOTRH/703/23) and the Moi Teaching and Referral Hospital-Institutional Research and Ethics Committee (IREC/533/2023 - 0004474. A research permit was obtained from the National Commission of Science, Technology and Innovation\u0026nbsp;(NACOSTI/P/24/35340). All study investigators completed a course on research ethics involving human subjects before engaging in the study. All participants provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe corresponding author confirms that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. KJ, MG and YD conceived of the study and were awarded the grant funding. KJ, MG, YD, EM, SA, and IA, led the training and data collection. CR and EM assisted with data quality checks, and MG, OO, KJ and CR designed the analysis plan and CR completed data cleaning, management and conducted data analysis.\u0026nbsp;All authors contributed to the interpretation of data and the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Hewlett Foundation (Grant #: 2022-01583-PRO) to the African Population and Health Research Center (APHRC), the Norwegian Agency for Development Cooperation (NADC) (Grant #: QZA-21/0135), and the Children\u0026apos;s Investment Fund Foundation (CIFF) (Grant #: 2012-05769) to the Guttmacher Institute\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe views expressed are those of the author(s) and not necessarily those of the funders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot commissioned; externally peer reviewed\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBearak JM, Popinchalk A, Beavin C, Ganatra B, Moller A-B, Tun\u0026ccedil;alp \u0026Ouml;, et al. 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Contracept X. 2022;4: 100087. doi:10.1016/j.conx.2022.100087\u003c/li\u003e\n\u003cli\u003eStillman M, Kibira SPS, Shiferaw S, Makumbi F, Seme A, Sully EA, et al. Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda. BMC Health Serv Res. 2023;23: 104. doi:10.1186/s12913-022-09017-8\u003c/li\u003e\n\u003cli\u003eMagalona S, Thomas HL, Akilimali PZ, Kayembe D, Moreau C, Bell SO. Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC. BMC Health Serv Res. 2023;23: 658. doi:10.1186/s12913-023-09647-6\u003c/li\u003e\n\u003cli\u003eThomas HL, Alzouma S, Oumarou S, Moreau C, Bell SO. Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data. BMC Health Serv Res. 2023;23: 1171. doi:10.1186/s12913-023-10107-4\u003c/li\u003e\n\u003cli\u003eOnadja Y, Compaor\u0026eacute; R, Yugbar\u0026eacute; DB, Thomas HL, Guiella G, Lougu\u0026eacute; S, et al. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res. 2024;24: 84. doi:10.1186/s12913-023-10538-z\u003c/li\u003e\n\u003cli\u003eOwolabi OO, Biddlecom A, Whitehead HS. Health systems\u0026rsquo; capacity to provide post-abortion care: a multicountry analysis using signal functions. Lancet Glob Health. 2019;7: e110\u0026ndash;e118. doi:10.1016/S2214-109X(18)30404-2\u003c/li\u003e\n\u003cli\u003eCompaor\u0026eacute; R, Mehrtash H, Calvert C, Qureshi Z, Bello FA, Baguiya A, et al. Health facilities\u0026rsquo; capability to provide comprehensive postabortion care in Sub-Saharan Africa: Evidence from a cross-sectional survey across 210 high-volume facilities. Int J Gynecol Obstet. 2022;156: 7\u0026ndash;19. doi:10.1002/ijgo.14056\u003c/li\u003e\n\u003cli\u003eBell SO, Shankar M, Ahmed S, OlaOlorun F, Omoluabi E, Guiella G, et al. Postabortion care availability, facility readiness and accessibility in Nigeria and C\u0026ocirc;te d\u0026rsquo;Ivoire. Health Policy Plan. 2021;36: 1077\u0026ndash;1089. doi:10.1093/heapol/czab068\u003c/li\u003e\n\u003cli\u003eWorld Health Organization \u0026amp; Alliance for Health Policy and Systems Research. Primary health care systems (primasys): case study from Kenya: abridged version. Geneva: World Health Organization; 2017. Report No.: WHO/HIS/HSR/17.6. Available: https://iris.who.int/handle/10665/341073\u003c/li\u003e\n\u003cli\u003eKungu W. Contraceptive use and discontinuation among women aged 15\u0026ndash;24 years in Kenya. Front Reprod Health. 2023;5. doi:10.3389/frph.2023.1192193\u003c/li\u003e\n\u003cli\u003eMwadhi MK, Bangha M, Wanjiru S, Mbuthia M, Kimemia G, Juma K, et al. Why do most young women not take up contraceptives after post-abortion care? An ethnographic study on the effectiveness and quality of contraceptive counselling after PAC in Kilifi County, Kenya. Sex Reprod Health Matters. 2023;31: 2264688. doi:10.1080/26410397.2023.2264688\u003c/li\u003e\n\u003cli\u003eMainah J, Keraka M, Otieno D. Role of Nurses in the Uptake of Comprehensive Abortion Care in Tier Three Health Facilities in Nairobi County. 2018. Available: https://www.semanticscholar.org/paper/Role-of-Nurses-in-the-Uptake-of-Comprehensive-Care-Mainah-Keraka/dbe405c679118aeb63e0c759eec3e06344cbeadb\u003c/li\u003e\n\u003cli\u003eYegon E, Ominde J, Baynes C, Ngadaya E, Kahando R, Kahwa J, et al. The Quality of Postabortion Care in Tanzania: Service Provider Perspectives and Results From a Service Readiness Assessment. Glob Health Sci Pract. 2019;7: S315\u0026ndash;S326. doi:10.9745/GHSP-D-19-00050\u003c/li\u003e\n\u003cli\u003eOkonofua F, Ntoimo L, Bury L, Bright S, Hoggart L. \u0026ldquo;When you provide abortion services, you are looked upon as a bad guy\u0026rdquo;: experiences of abortion stigma by health providers in Nigeria. Glob Health Action. 2024;17: 2401849. doi:10.1080/16549716.2024.2401849\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e All Level V and Level IV facilities offered PAC. All but 1 Level IV facility in the sample provided PAC.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e Methods for the removal of retained products of conception include manual or electric vacuum aspiration (MVA/EVA), dilation and evacuation (D\u0026amp;E), dilation and curettage (D\u0026amp;C), or medication abortion (misoprostol alone or in combination with mifepristone).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e The 2019 study was not nationally representative as only seven counties out of the 47 were included. The sample size was also smaller and only had about 253 facilities compared to the 658 in this study.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Post-abortion care, Abortion, Health systems, Capacity, Quality of Post-abortion care, Signal functions","lastPublishedDoi":"10.21203/rs.3.rs-7305576/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7305576/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eUnderstanding a health system\u0026rsquo;s capacity to provide post-abortion care (PAC) offers crucial insights into the strengths, gaps, and weaknesses in delivering high-quality PAC services. In Kenya and elsewhere, inadequate data limits the ability of policy actors to prioritize critical interventions and investments for improving maternal healthcare. This study examined the capacity of health facilities in Kenya to provide PAC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis paper uses data from a 2023 health facility survey conducted across a nationally representative sample of health facilities in Kenya to explore the capacity of health facilities to provide PAC. Data were collected on PAC signal function indicators, including the availability of services, equipment, supplies, and staffing over the last six months, and the readiness to provide PAC on the day of the survey. A descriptive analysis was conducted to estimate the proportion of facilities that meet the criteria for availability and readiness for each individual signal function definition and report these findings by facility level and ownership (public vs. private).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eUsing the availability criteria, we estimate that 18.3% of primary-level health facilities meet the definition for basic PAC, and 24.1% of referral health facilities meet the definition for comprehensive PAC. These proportions drop when using the more stringent readiness definition (basic PAC for primary health facilities\u0026thinsp;=\u0026thinsp;3.3%, comprehensive PAC for referral health facilities\u0026thinsp;=\u0026thinsp;7.2%). The most significant drivers of reduced PAC availability and readiness include the inability to provide at least three types of short-acting contraceptives post-abortion, a lack of providers on-staff who are trained on PAC, and the inability to provide surgical operations among referral facilities.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur findings confirm the need to enhance PAC services in Kenya by addressing the existing gaps in service provision. There is a need to pursue the full implementation of the PAC standards and assessment tools that streamline facility staffing, training, and supply of PAC commodities and equipment at all levels.\u003c/p\u003e","manuscriptTitle":"Assessing the availability and readiness of health facilities to provide post-abortion care in Kenya: Results from a nationwide Health Facility Survey, 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 14:35:53","doi":"10.21203/rs.3.rs-7305576/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"199309179249858758108648781904372215602","date":"2025-09-05T14:20:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T10:44:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T05:21:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-11T06:37:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-10T06:52:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-10T06:49:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbdcbb7d-0eff-4c0f-b55f-f4a592b7dafc","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T14:35:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-12 14:35:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7305576","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7305576","identity":"rs-7305576","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}