| 1. |
- Iyengar, Kirti, et al.
(författare)
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Home use of misoprostol for early medical abortion in a low resource setting : secondary analysis of a randomized controlled trial
- 2016
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 0001-6349 .- 1600-0412. ; 95:2, s. 173-181
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol as compared to clinic misoprostol in a low-resource setting.MATERIAL AND METHODS: This was a secondary analysis of a randomised controlled trial conducted in 6 primary care clinics in India. Women seeking medical abortion up to 9 gestational weeks (n= 731) received mifepristone in the clinic, and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days.RESULTS: Of 731 participants, 73% were rural and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2% and 94.4% respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion, than the proportion of clinic users (79.7%) that would opt for misoprostol at the clinic, in a similar situation (p=0.0002). Ninety six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience.CONCLUSIONS: Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.
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| 2. |
- Paul, Mandira, 1985-, et al.
(författare)
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Acceptability of home-assessment post medical abortion and medical abortion in a low-resource setting in Rajasthan, India : Secondary outcome analysis of a non-inferiority randomized controlled trial
- 2015
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Ingår i: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 10:9
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Tidskriftsartikel (refereegranskat)abstract
- Background: Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education.Objective: To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India.Design: Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India.Population: Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years.Methods: Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1: 1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible.Main outcome measures: Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups.Results: 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001).Conclusion: Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.
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| 3. |
- Paul, Mandira, 1985-, et al.
(författare)
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Barriers and facilitators in the provision of post-abortion care at district level in central Uganda – a qualitative study focusing on task sharing between physicians and midwives
- 2014
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Ingår i: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 14:28
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundAbortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians’ and midwives’ perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care.MethodsIn-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach.ResultsPost-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified.ConclusionsTask sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.
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| 4. |
- Paul, Mandira, 1985-, et al.
(författare)
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Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial
- 2016
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Ingår i: BMC Public Health. - : Springer Science and Business Media LLC. - 1471-2458. ; 16:1
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion.METHODS: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114).RESULTS: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use.CONCLUSIONS: Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods.TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995.
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| 5. |
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| 6. |
- Paul, Mandira, 1985-, et al.
(författare)
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Negotiating collective and individual agency : a qualitative study of young women's reproductive health in rural India
- 2017
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Ingår i: Qualitative Health Research. - : SAGE Publications. - 1049-7323 .- 1552-7557. ; 27:3, s. 311-324
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Tidskriftsartikel (refereegranskat)abstract
- The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.
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| 7. |
- Paul, Mandira, 1985-, et al.
(författare)
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Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India : study protocol and intervention adaptation of a randomised control trial
- 2014
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Ingår i: BMC Women's Health. - : BioMed Central. - 1472-6874. ; 14
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Tidskriftsartikel (refereegranskat)abstract
- The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic.Trial designThe study is a randomised, controlled, non-superiority trial .MethodsWomen screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study is to evaluate the effectiveness of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This was to optimise and tailor-make the intervention and the study procedures and resulted in the development of the pictorial instruction sheet for how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion. DiscussionIn this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor. Trial registration: Clinicaltrials.gov NCT01827995. Registered 04 May 2013
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| 8. |
- Paul, Mandira, 1985-
(författare)
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Simplifying Reproductive Health in Low-Resource Settings : Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- India introduced family planning in the ‘50s, legalized abortion in the ‘70s, and accomplished a remarkable drop in maternal mortality and fertility since 1990. Nevertheless, abortions account for a large proportion of maternal deaths, and sterilization is the most frequently used contraception. This thesis aims to identify the means to simplify and increase access to reproductive health in low-resource settings, focusing on abortion and contraception in Rajasthan.A randomized controlled trial compared simplified follow-up, where women assess their abortion outcome at home after early medical abortion, with in-clinic follow-up. Additionally, contraceptive use was compared between study groups post-abortion. In order to explore young women’s opportunities to access reproductive health services in the area, we conducted in-depth interviews with recently-married women.Women in the home-assessment group preferred home-assessment in the future to a greater extent than the women in the clinic follow-up group, who preferred in-clinic follow-up. Complete abortions were reported in 95% of women in the ‘home-assessment group’ and 93% in the ‘in-clinic group’, suggesting that efficacy of simplified follow-up is non-inferior to in-clinic follow-up. A majority (81%) of women carried out the pregnancy test and found it easy to use. Women (96%) were satisfied with their abortion. There were no differences in contraceptive use between study groups at three months; however, women in the ‘in-clinic group’ were most likely to initiate contraception at two weeks. A majority of women preferred the three-month injection, while only 4% preferred sterilization. The recently-married women considered reversible contraception to be unfeasible due to misconceptions and taboos, yet women wanted effective contraception because their current use of traditional methods resulted in unintended pregnancies. Abortions were common, and were procured from private or informal providers.Allowing women to take an active role in reproductive health services can enable simplification of, and access to, reproductive services in low-resource settings as well as in other settings. Simplifying medical abortion, providing contraception ‘intra-abortion’, and offering a context-appropriate and effective means of contraception, creates a great potential to increase access to reproductive health services and can result in a more equal society where women, and men, can attain their sexual and reproductive rights.
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| 9. |
- Paul, Mandira, 1985-, et al.
(författare)
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The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion
- 2015
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Ingår i: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 8, s. 1-4
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Tidskriftsartikel (refereegranskat)abstract
- With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.
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