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- Atuhairwe, Susan, et al.
(författare)
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Evaluating the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians : study protocol for a randomized controlled equivalence trial
- 2019
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Ingår i: Trials. - : Springer Science and Business Media LLC. - 1745-6215. ; 20:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: A large proportion of abortion-related mortality and morbidity occurs in the second trimester of pregnancy. The Uganda Ministry of Health policy restricts management of second-trimester incomplete abortion to physicians who are few and unequally distributed, with most practicing in urban regions. Unsafe and outdated methods like sharp curettage are frequently used. Medical management of second-trimester post-abortion care by midwives offers an advantage given the difficulty in providing surgical management in low-income settings and current health worker shortages. The study aims to assess the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians.METHODS: A randomized controlled equivalence trial implemented at eight hospitals and health centers in Central Uganda will include 1192 eligible women with incomplete abortion of uterine size > 12 weeks up to 18 weeks. Each participant will be randomly assigned to undergo a clinical assessment and treatment by either a midwife (intervention arm) or a physician (control arm). Enrolled participants will receive 400 μg misoprostol administered sublingually every 3 h up to five doses within 24 h at the health facility until a complete abortion is confirmed. Women who do not achieve complete abortion within 24 h will undergo surgical uterine evacuation. Pre discharge, participants will receive contraceptive counseling and information on what to expect in terms of side effects and signs of complications, with follow-up 14 days later to assess secondary outcomes. Analyses will be by intention to treat. Background characteristics and outcomes will be presented using descriptive statistics. Differences between groups will be analyzed using risk difference (95% confidence interval) and equivalence established if this lies between the predefined range of - 5% and + 5%. Chi-square tests will be used for comparison of outcome and t tests used to compare mean values. P ≤ 0.05 will be considered statistically significant.DISCUSSION: Our study will provide evidence to inform national and international policies, standard care guidelines and training program curricula on treatment of second-trimester incomplete abortion for improved access.TRIAL REGISTRATION: ClinicalTrials.gov, NCT03622073 . Registered on 9 August 2018.
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- Cleeve, Amanda, et al.
(författare)
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Abortion as agentive action: reproductive agency among young women seeking post-abortion care in Uganda
- 2017
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Ingår i: Culture, Health and Sexuality. - : Informa UK Limited. - 1369-1058 .- 1464-5351. ; 19:11, s. 1286-1300
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Tidskriftsartikel (refereegranskat)abstract
- Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one's body and future. Women's experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.
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| 4. |
- Cleeve, Amanda, et al.
(författare)
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Morality versus duty - A qualitative study exploring midwives' perspectives on post-abortion care in Uganda
- 2019
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Ingår i: Midwifery. - : Elsevier BV. - 0266-6138 .- 1532-3099. ; 77, s. 71-77
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care.DESIGN: This was a qualitative study using individual in-depth interviews and an inductive thematic analysis.SETTING AND PARTICIPANTS: Interviews were conducted with 22 midwives (the 'informants') providing PAC in a public hospital in Kampala, Uganda. The narratives were based on experiences in current and previous workplaces, in rural and urban settings.FINDINGS: The findings comprise one main theme - morality versus duty to provide quality post-abortion care - and three sub-themes. Our findings confirm that the midwives were committed to saving women's lives but had conflicting personal morality in relation to abortion and sense of professional duty, which seemed to influence their quality of care. Midwives were proud to provide PAC, which was described as a natural part of midwifery. However, structural challenges, such as lack of supplies and equipment and high patient loads, hampered provision of good quality care and left informants feeling frustrated. Although abortion was often implied to be immoral, the experience of PAC provision appeared to shape views on legality, leading to an ambiguous, yet more liberal, stance. Abortion stigma was reported to exist within communities and the health workforce, extending to both providers and care-seeking women. Informants had witnessed mistreatment of women seeking care due to abortion complications, through deliberate care delays and denial of pain medication.KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives in PAC were dedicated to saving women's lives; however, conflicting morality and duty and poor working conditions impeded quality of care. Enabling midwives to provide good quality care includes increasing the patient-midwife ratio and ensuring essential resources are available. Additionally, efforts that de-stigmatise abortion and promote accountability are needed. Implementation of policies on respectful post-abortion care could aid in ensuring all women are treated with respect.
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- Cleeve, Amanda, et al.
(författare)
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Women's acceptability of misoprostol treatment for incomplete abortion by midwives and physicians : secondary outcome analysis from a randomized controlled equivalence trial at district level in Uganda
- 2016
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Ingår i: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 11:2
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians.METHODS: This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14-28 days following treatment. Analysis of women's overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024.RESULTS: From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded.CONCLUSIONS: Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women.TRIAL REGISTRATION: ClinicalTrials.gov NCT01844024.
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- Klingberg-Allvin, Marie, et al.
(författare)
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Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda : a randomised controlled equivalence trial
- 2015
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Ingår i: The Lancet. - 0140-6736 .- 1474-547X. ; 385:9985, s. 2392-2398
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians.METHODS: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14-28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model. The predefined equivalence range was -4% to 4%. The trial was registered at ClinicalTrials.gov, number NCT01844024.FINDINGS: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was -0·8% (95% CI -2·9 to 1·4), falling within the predefined equivalence range (-4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded.INTERPRETATION: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives' involvement in treatment of incomplete abortion with misoprostol at district level would increase access to safe post-abortion care.FUNDING: The Swedish Research Council, Karolinska Institutet, and Dalarna University.
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