A qualitative exploration of moderating factors shaping implementation fidelity to post-abortion care guidelines in a rural district of Zambia

Background: The Zambian government introduced the standards and guidelines for comprehensive abortion care in 2017, to address the high number of maternal deaths resulting from unsafe abortions among women and girls. However, there is little information regarding how the guidelines on post abortion care (PAC) are being adhered to by providers in some rural settings. This study explored the moderating factors shaping implementation fidelity to post-abortion care guidelines in rural health facilities of Chibombo District, Zambia. Methods: The study utilized a qualitative case study design, comprising key informant interviews with program managers (n = 4) and in-depth interviews with PAC providers (n = 22). Purposive-homogenous sampling was employed to specifically include current PAC providers from health facilities within the study district. The data was subsequently analyzed using thematic analysis. Results: The involvement and support from local leaders and stakeholders such as traditional leaders, non-governmental organizations (NGOs) and the district health office as well as effective monitoring and communication strategies put in place, positively contributed to PAC provider’s adhering to the guidelines. However, there were several barriers to the use of the guidelines such as late dissemination and unavailability of revised PAC guidelines, lack of reference to the guidelines due to work overload, lack of resources stipulated in the guidelines to provide the services and gaps in technical support, such as training, supervision, and supplies, created by withdrawing NGOs. Conclusion: The study underscores that adherence to PAC guidelines is significantly influenced by contextual factors, rather than inherent shortcomings in the guidelines. The challenges identified in the study district predominantly arise from external health system barriers. These include ineffective dissemination, inadequate allocation of resources, insufficient training, and gaps in technical support. Addressing these systemic challenges will be crucial in enhancing adherence to PAC guidelines and ultimately improving the quality of care for women in need of post-abortion services.