Pathways to care among women hospitalized with severe abortion complications in Bangui, Central African Republic, a conflict-affected urban setting: qualitative results of the AMoCo (abortion-related morbidity and mortality in conflict-affected and fragile settings) study.

backgroundThe Central African Republic (CAR), a fragile and conflict-affected setting, has one of the highest maternal mortality ratios in the world. Complications of unsafe abortion, while preventable, are one of the major contributors. Legal abortion is authorized in limited circumstances before eight weeks but in practice, is unavailable. This study explored the experiences of patients hospitalized with severe postabortion complications at a Ministry of Health (MoH) maternity hospital supported by Médecins sans Frontières to understand women's challenges accessing appropriate care.

methodsWe interviewed 18 purposively selected girls and women following medical treatment for near-miss or potentially life-threatening abortion complications. In-depth interviews were conducted to understand women's challenges accessing appropriate care. Data were analysed thematically to identify patterns in decisions, care-seeking trajectories, and factors that may have delayed seeking and receiving postabortion care.

resultsAbout two-thirds of participants reported that they had induced the abortion, either on their own or with assistance, before seeking postabortion care. Participants faced multiple barriers accessing abortion which led them to choose ineffective and harmful abortion methods, notably a lack of reliable information and access to safe abortion care services, compounded by individual, interpersonal and socio-economic constraints. When experiencing postabortion complications, the decision to seek care was delayed by limited knowledge and attempts at maintaining secrecy surrounding the abortion. Participants, including those not reporting induced abortion, described complex nonlinear care-seeking pathways, including attempts to self-manage symptoms and consulting closer health care facilities that weren't able to handle the complications due to lack of capacity. Postabortion complications were associated with taxing and potentially long-term physical, psychological, social and financial consequences, which often negatively impacted women, families and communities.

conclusionsOur findings highlight the urgent need for MoH and partners to implement strategies improving timely access to high-quality postabortion care, such as informing communities about danger signs of abortion complications, treatment locations, improving referral systems, and reducing financial barriers. Training informal and lower-level medical staff in the recognition and treatment of abortion complications and about respectful non-judgmental communication with patients would also be of benefit. Furthermore, creating a more supportive environment for the provision of postabortion and safe abortion care and information should be prioritized, including the decentralisation of care to primary care facilities.