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To address the need for a global measurement standard to evaluate the quality of abortion care, the 4-year Abortion Service Quality (ASQ) Initiative developed, tested, and validated a simple, effective metric to assess the quality of abortion service provision both in facilities and at out-of-facility locations.

Phase 1:

Led by Metrics for Management, Ibis Reproductive Health, and Ipas, the ASQ Initiative collected and collated existing tools in use by NGOs, clinics, and ministries, across 80 countries, to identify common indicators and determine which are most valuable in measuring ASQ. Having identified over 1000 unique indicators in use, ASQ Initiative researchers then collaborated with the ASQ Resource Group, made up of reproductive health experts from NGOs, Ministries of Health, service providers, research institutions, advocates, and funding bodies, to develop a reduced, universally effective set of indicators. The indicators include both person-centered, and technical and safety indicators.

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Phase 2:

To ensure that the resulting indicators and the final assessment tool appropriately addressed clients’ concerns and values for quality of care, the second phase of the ASQ Initiative’s work included interviews and focus group input from individuals in Argentina, Bangladesh, Ethiopia, and Nigeria who had received abortion services. These individuals represented the breadth of modern abortion service pathways, including referral and hotline options, pharmacies, clinics, and inpatient abortion services. Focus groups intentionally included vulnerable groups such as young people, those whose abortion occurred after 12 weeks of gestation, and individuals who had had more than one abortion. Findings from these engagements contributed to the development of 39 new client-centered indicators that were added to the list of potential ASQ indicators.

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Phase 3:

The final phase was field testing the possible 111 indicators (72 technical quality indicators and 39 client-centered indicators) against 12 possible outcomes (see below) in Bangladesh, Ethiopia, and Nigeria. Pilot testing was conducted with partners from public and private facilities, NGOs, pharmacies, and hotlines. In each country, three regions were selected to represent the diversity of the population, and the sample was drawn from existing sampling frames in each country, which varied by country and site type. If a selected site declined to participate, was no longer providing abortion services, or if the security situation did not allow for data collection, the site was replaced with the next site sampled through probability proportional to size (PPS) sampling. Hotlines were not sampled; they were selected purposively. One hotline was purposively selected in Bangladesh and one in Nigeria. In Ethiopia, sites with a higher proportion of clients with a gestational age at or after 13 weeks were oversampled to ensure representation of this important group.

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12 Outcomes

Client-level outcomes

  1. Client was treated with respect and kindness throughout the abortion process
  2. Client felt that they could cope with their pain
  3. Client felt they knew what to do if adverse events occurred
  4. Client was able to access follow-up or intervention for issues related to the abortion as desired
  5. Client knew their abortion was complete or had a plan for what to do
  6. Client was able to access ancillary services or referrals, such as contraceptive and STI/HIV services, if desired
  7. Client was no longer pregnant at 30 days
  8. Client experienced abortion-related infection
  9. Client would recommend the service to a friend

Facility-level outcomes

  1. Deaths
  2. Serious adverse events (e.g. blood transfusion, surgery, transfer to a higher level facility)
  3. Clients turned away for abortion services
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