Study design and period

A health facility-based cross-sectional study design was employed for this study from March, 1 to 30/2021.

Study area

The study was conducted in the public health facilities of Bahir Dar city. Bahir Dar City is the capital city of the Amhara Region and is located approximately 565 km northwest of Addis Ababa, the capital city of Ethiopia. The estimated population of the city for the year 2020/21 is about 518, 193 of which 265,156 are females [35]. In the city, there are 3 public hospitals and six public health centers, 4 private general hospitals, 34 private medium clinics, 6 private lower clinics, and 3 Nongovernmental Organization clinics. All the public health facilities provide comprehensive abortion care services and the services are free for all women. There are 1757 health providers in the three public hospitals and six health centers of the city. Of these, 973 were female health workers.

Source population

All health care providers who were working at the public health facilities of Bahir Dar city.

Study population

Randomly selected healthcare providers who are working at the public health facilities of Bahir Dar City during the data collection period.

Inclusion and exclusion criteria

Health professionals who are working in clinical departments such as general nurses, midwives, health officers, integrated emergency surgery officers, general practitioners, and specialists who were present during data collection time were included, while health care providers like pharmacists, laboratory technicians, radiology, environmental health, and free service health care providers were excluded.

Sample size determination

The sample size was calculated using a single population proportion formula by considering the following assumptions: the proportion of health care providers who had a good attitude towards safe abortion care taken from the previous study 56.7% [36], Zα/2 = critical value for normal distribution at 95% confidence level, which is equal to 1.96 (Z value of alpha = 0.05) or 5% level of significance (α = 0.05) and a 5% margin of error (ω = 0.05). Then the sample size was calculated as follows (n = (Z/2)2p (1-p)/d2), (n = (1.96)2 0.567 (1–0.567)/0.052) = 377. The sample size was adjusted by adding a 10% non-response rate and the final sample size was 377*10 = 416 health care providers.

Sampling procedure and techniques

In Bahir Dar city, there are three public hospitals and six public health centers and all of these public health facilities of Bahir Dar city were included in this study. The total sample size was proportionally allocated for each public health facility of the city based on their total number of health care providers. Before data collection, the census was conducted to identify healthcare providers in each public health facility.

After the census, the total number of healthcare providers in the public health facility of the city was 1,758. The numbers of health care providers in Felege Hiwot Comprehensive Specialized Hospital (n = 847), Tibebe Gion specialized hospital (n = 576), Addisalem Primary Hospital (n = 154), and the six public health centers, including Bahir Dar health center, Han health center, Dagimawi Minilik health center, Shimbit health center, Shumoabo health center and Abaymado health center (n = 181). The total sample size was proportionally allocated for each health facility, based on its population size. The total sample size after proportional allocation was 201 for Felege Hiwot Comprehensive Specialized Hospital, 136 for Tibebe Gion Specialized Hospital, 36 for Addisalem Primary Hospital, and 43 for the six public health centers of the city. The study participants were selected by a computer-based simple random sampling technique.

Study variablesDependent variable

The attitude of health care providers towards safe abortion care (favorable/ unfavorable).

Independent variables

Socio-demographic factors (age, sex, marital status, and religion), health facility-related factors (type of health facilities, profession, work experience, and work unit), knowledge of safe abortion and awareness of the revised law, and practice-related factors (having training and practicing abortion procedure).

Operational definitions Attitude toward safe abortion care

Refer to the attitude of health care providers towards safe abortion care and assessed using 20 questions by assigning + 1 for strongly disagree, + 2 for disagree, + 3 for neutral, + 4 for agree, and + 5 for strongly agree. Health care provider was considered to have a favorable attitude toward safe abortion care if he/she correctly answered greater than or equal to the mean score of the total attitude towards safe abortion assessing questions and those who scored less than the mean score were considered as having an unfavorable attitude towards safe abortion care [36].

Knowledge

Refers to the knowledge of health care providers about abortion and it has been assessed using 48 composite variables by assigning + 1 for a correct answer and 0 for an incorrect answer. Health care provider was considered to have good knowledge of abortion if he/she correctly answered greater than or equal to the mean score of the total knowledge of abortion assessing questions and those who scored less than the mean score were considered as having poor knowledge of abortion [37].

Further revision of abortion law: legalization of abortion which is open or unrestricted law as compared to the current law [36].

Awareness

Refers to the awareness of the revised abortion law of the country and it has been assessed using 5 composite variables by assigning + 1 for a correct answer and 0 for an incorrect answer. Healthcare provider was considered to have a good awareness of the revised abortion law if he/she correctly answered greater than or equal to the mean score of the total awareness of the revised abortion law assessing questions and those who scored less than the mean score were considered as having of poor awareness of the revised abortion law of the country.

Health care provider

A health care provider is an individual health professional licensed to provide services to the patient which includes midwives, nurses, health officers, general practitioners, integrated emergency surgery officers, and specialists [30, 38].

Data collection tools and procedures

A structured self-administered questionnaire was used to collect the data which were adapted from relevant works of literature and modified to the local context [26, 30, 32, 36]. The questionnaires were prepared in the English language. The questionnaire consisted of socio-demographic characteristics, source of information-related factors, health facility-related factors, attitude, knowledge, and practice-related factors questions. A Pre-tested structured interviewer-administered questionnaire was used for data collection purposes. The data were collected by six diploma midwives and supervised by two BSc midwives.

Data quality control

Data were collected by trained data collectors and pretesting of the instrument was done before the actual data collection. The questionnaire was pre-tested before the actual data collection period on 21 healthcare providers, or (5%) of the sample size at Dangila Primary Hospital, to assess the reliability, clarity, sequence, consistency, understandability, and the total time it takes to finish the questionnaire. Data collectors and supervisors were trained for two days by the investigator. After necessary modifications and correction was done to standardize and ensure its reliability and validity additional adjustments were made based on the results of the pre-test. The Cronbach alpha score for the pretest was 0.8. The completeness of the data was checked by data collectors during data collection and daily supervision was done for data completeness by supervisors.

Data processing and statistical analysis

The data were entered into Epi data 4.2, edited and cleaned for inconsistencies, missing values, and outliers, and then exported to SPSS version 25.0 for analysis. During analysis, all explanatory variables that have a significant association in bivariate analysis with a P-value < 0.25 were entered into a multivariable logistic regression model to get AOR and those variables with 95% CI and a P-value of < 0.05 were considered as statistically significant with a favorable attitude of health care provider towards safe abortion care. The multicollinearity test was done using the variance inflation factor and there was no collinearity between the independent variables. The model goodness of the test was checked by using Hosmer- Lemeshow goodness of the fit and its P-value was 0.215. Frequency tables, figures, and descriptive summaries were used to describe the study variables. A preprint version of the paper has previously been published, Tadie A. et al. https://doi.org/10.21203/rs.3.rs-2305231/v1 [39].