When Incident Rates Mislead: An Integrated Safety and Quality Analysis of FP/PAC Services in Sierra Leone
Abstract:
Safety monitoring in family planning (FP) and post-abortion care (PAC) services in low- and middle-income countries (LMICs) relies on safety flags and incident rates, yet these indicators are rarely interpreted together. This creates a risk that incident rate differences between service delivery channels may be misread as quality deficits when they reflect differences in service scope and case complexity. This study examined safety flags, incident rates, and quality assessment performance in an integrated framework across centre-based facilities and outreach teams in a Sierra Leone FP/PAC programme. A longitudinal observational analysis used 108 Quality Technical Assessment (QTA) records from 23 paired service delivery points across 14 districts (2019–2022). Safety flags and safety domain scores were compared between remote and in-person assessment modalities using chi-square and Mann-Whitney U tests. Clinical and product incident rates per 1,000 couple-years of protection (CYP) were compared between channels. Domain-specific QTA scores were compared across eight quality domains. Safety flags did not differ significantly between modalities (p = .740). Centre-based facilities showed significantly higher incident rates than outreach services (U = 0.00, Z = −2.309, p = .021, r = −0.82). Despite this, no significant channel differences were observed in composite QTA final scores (p = .448) or in any of the eight quality domains. The divergence between higher incident rates at centres and equivalent quality scores indicates the difference reflects structural differences in service scope and case complexity rather than quality deficits. These findings support integrated safety frameworks in reproductive health programme monitoring.References:
[1].
Sprockett A,
2017, Review of quality assessment tools for family planning programmes in low-
and middle-income countries. Health Policy Plan. 32(2), 292-302. Available
from: https://doi.org/10.1093/heapol/czw144
[2].
Donabedian A,
2003, An introduction to quality assurance in health care. Oxford University
Press, New York.
[3].
Bruce J, 1990,
Fundamental elements of the quality of care: a simple framework. Stud Fam
Plann. 21(2), 61-91. Available from: https://doi.org/10.2307/1966525
[4].
Rowe SY,
Ross-Degnan D, Peters DH, Holloway KA, Rowe AK, 2022, The effectiveness of
supervision strategies to improve health care provider practices in low- and
middle-income countries: secondary analysis of a systematic review. Hum Resour
Health. 20, 1. Available from: https://doi.org/10.1186/s12960-021-00695-3
[5].
Oluwatola OA,
Phelan A, Nellums LB, et al., 2025, Influence of staffing on quality of care in
low- and middle-income countries: a systematic review. Health Policy Plan.
40(2), 143-56. Available from: https://doi.org/10.1093/heapol/czae113
[6].
Ayelign A, Zerfw
T, Liben ML, et al., 2025, Assessing health systems' capacities to provide
post-abortion care: insights from seven low- and middle-income countries. J
Glob Health. 15, 04020. Available from: https://doi.org/10.7189/jogh.15.04020
[7].
Pasquier E, Moch
M, Pinel A, et al., 2023, Abortion-related complications in fragile settings in
sub-Saharan Africa: a retrospective population-based study. Reprod Health.
20(1), 68. Available from: https://doi.org/10.1186/s12978-023-01613-3
[8].
Simmons M, Brown
J, Willems J, 2022, Remote general practice supervision with video cameras.
Aust J Gen Pract. 51(9), 696-702. Available from: https://doi.org/10.31128/AJGP-10-21-6213
[9].
Hatef E, Wilson
RF, Zhang A, et al., 2024, Effectiveness of telehealth versus in-person care
during the COVID-19 pandemic: a systematic review. npj Digit Med. 7(1), 157.
Available from: https://doi.org/10.1038/s41746-024-01138-4
[10]. Hancock NL, Stuart GS, Tang JH, Chibwesha CJ, Stringer
JSA, Chi BH, 2016, Renewing focus on family planning service quality globally.
Contracept Reprod Med. 1, 1. Available from: https://doi.org/10.1186/s40834-016-0010-9
[11]. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S,
Salomon JA, 2018, Mortality due to low-quality health systems in the universal
health coverage era: a systematic analysis of amenable deaths in 137 countries.
Lancet. 392(10160), 2203-12. Available from: https://doi.org/10.1016/S0140-6736(18)31668-4
[12]. World Health Organization, 2018, Delivering quality
health services: a global imperative for universal health coverage. WHO,
Geneva. Available from: https://www.who.int/publications/i/item/9789241513906
[13]. Statistics Sierra Leone and ICF, 2020, Sierra Leone
Demographic and Health Survey 2019. Stats SL and ICF, Freetown and Rockville.
Available from: https://dhsprogram.com/publications/publication-FR365-DHS-Final-Reports.cfm
[14]. Muga W, Owuor P, Njoroge A, et al., 2024, Barriers to
post-abortion care service provision in Burkina Faso, Kenya and Nigeria. BMC
Health Serv Res. 24, 112. Available from: https://doi.org/10.1186/s12913-024-10574-3
[15]. Hobbs AJ, Mannava P, Hoope-Bender P, et al., 2019,
Delivering quality health services: a global framework for action. Int J Qual
Health Care. 31(Suppl 1), 1-3. Available from: https://doi.org/10.1093/intqhc/mzy242
[16]. Semaan A, Sidney Annerstedt K, Beňová L, et al., 2023,
Provision and utilization of maternal health services during the COVID-19
pandemic in 16 hospitals in sub-Saharan Africa. Front Glob Womens Health. 4,
1192473. Available from: https://doi.org/10.3389/fgwh.2023.1192473
[17]. Odendaal WA, Anstey Watkins J, Leon N, et al., 2020,
Health workers' perceptions and experiences of using mHealth technologies to
deliver primary healthcare services: a qualitative evidence synthesis. Cochrane
Database Syst Rev. 3, CD011942. Available from: https://doi.org/10.1002/14651858.CD011942.pub2
[18]. Rowe AK, de Savigny D, Lanata CF, Victora CG, 2005,
How can we achieve and maintain high-quality performance of health workers in
low-resource settings? Lancet. 366(9490), 1026-35. Available from: https://doi.org/10.1016/S0140-6736(05)67028-6
[19]. World Health Organization, 2019, WHO Guideline:
Recommendations on Digital Interventions for Health System Strengthening. WHO,
Geneva. Available from: https://www.who.int/publications/i/item/9789241550505
[20]. Bogale GG, Amde WK, Kasaye HK, Mwangi W, 2024, Factors
associated with quality of family planning counselling in health facilities of
sub-Saharan Africa: a systematic review. Reprod Health. 21(1), 14. Available
from: https://doi.org/10.1186/s12978-024-01741-8
[21]. McCool J, Dobson R, Muinga N, et al., 2020, Factors
influencing the sustainability of digital health interventions in low-resource
settings: lessons from five countries. J Glob Health. 10(2), 020396. Available
from: https://doi.org/10.7189/jogh.10.020396
[22]. Damschroder LJ, Reardon CM, Widerquist MAO, Lowery J,
2022, The updated Consolidated Framework for Implementation Research based on
user feedback. Implement Sci. 17(1), 75. Available from: https://doi.org/10.1186/s13012-022-01245-0
[23]. Bradley S, Kamwendo F, Masanja H, et al., 2013,
District health managers' perceptions of supervision in Malawi and Tanzania.
Hum Resour Health. 11, 43. Available from: https://doi.org/10.1186/1478-4491-11-43
[24]. Desta BF, Beshir IA, Tefera BB, et al., 2020, Does
frequency of supportive supervisory visits influence health service delivery? A
dose-response study. PLoS ONE. 15(6), e0234819. Available from: https://doi.org/10.1371/journal.pone.0234819
[25]. Sultan MA, Miller E, Tikkanen RS, et al., 2025, Competency-based education and training for community health workers: a scoping review. BMC Health Serv Res. 25(1), 263. Available from: https://doi.org/10.1186/s12913-025-12403-7
