| 1. |
- 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 Unsafe and outdated methods like sharp curettage are frequently used.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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| 2. |
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| 3. |
- Makenzius, Marlene, et al.
(författare)
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Contraceptive uptake in post abortion care-Secondary outcomes from a randomised controlled trial, Kisumu, Kenya.
- 2018
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Ingår i: PLOS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 13:8
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Tidskriftsartikel (refereegranskat)abstract
- AIM: The aim was to explore contraceptive uptake, associated factors and satisfaction among post abortion-care (PAC) seeking women in Kenya. Due to unsafe abortions, almost 120 000 Kenyan women received PAC in 2012, and of these women, 70% did not use contraception before pregnancy.METHODS: This study was nested in a larger randomised controlled trial, where 859 women sought PAC at two public hospitals in Kisumu, in June 2013-May 2016. The women were randomly assigned to a midwife or a physician for PAC, including contraceptive counselling, and followed up at 7-10 days and three months. Associated factors for contraceptive uptake were analysed with binary logistic regression, and contraceptive method choice, adherence and satisfaction level were examined by descriptive statistics, using IBM SPSS Statistics for Windows, Version 22.0.RESULTS: Out of the 810 PAC-seeking women, 76% (n = 609) accepted the use of contraception. Age groups of 21-25 (OR: 2.35; p < 0.029) and 26-30 (OR: 2.22; p < 0.038), and previous experience of 1-2 gravidities (OR 1.939; p = 0.018) were independent factors associated with the up-take. Methods used: injections 39% (n = 236); pills 27% (n = 166); condoms 25% (n = 151); implant 7% (n = 45) and intrauterine device (IUD) 1% (n = 8). At 3-month follow-up of the women (470/609; 77%), 354 (75%) women still used contraception, and most (n = 332; 94%) were satisfied with the method. Reasons for discontinuation were side-effects (n = 44; 39%), partner refusal (n = 27; 24%), planned pregnancy (n = 27; 24%) and lack of resupplies (n = 15; 13%).CONCLUSIONS: PAC-seeking women seem highly motivated to use contraceptives, yet a quarter decline the use, and at 3-month follow-up a further quarter among the users had discontinued. Implant, IUD and permanent method are rarely used. Strategies to improve contraceptive counselling, particularly to adolescent girls, and to increase access to a wide range of methods, as well as provider training and supervision may help to improve contraceptive acceptance and compliance among PAC-seeking women in Kisumu, Kenya.
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| 4. |
- Makenzius, Marlene, et al.
(författare)
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Post-abortion care with misoprostol - equally effective, safe and accepted when administered by midwives compared to physicians : a randomised controlled equivalence trial in a low-resource setting in Kenya
- 2017
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Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 7:10
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To assess the effectiveness of midwives administering misoprostol to women with incomplete abortion seeking post-abortion care (PAC), compared with physicians.DESIGN: A multicentre randomised controlled equivalence trial. The study was not masked.SETTINGS: Gynaecological departments in two hospitals in a low-resource setting, Kenya.POPULATION: Women (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis.INTERVENTIONS: 600 µg misoprostol orally, and contraceptive counselling by a physician or midwife.MAIN OUTCOME MEASURES: Complete abortion not needing surgical intervention within 7-10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was -4% to 4%. Secondary outcomes were analysed descriptively.RESULTS: The proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (-4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7-10 days occurred in 76% (613/810). No serious adverse events were recorded.CONCLUSIONS: Treatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception.TRIAL REGISTRATION NUMBER: NCT01865136; Results.
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| 5. |
- 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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| 6. |
- Persson, Maria, et al.
(författare)
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A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh
- 2021
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Ingår i: Conflict and Health. - : BioMed Central (BMC). - 1752-1505. ; 15
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Tidskriftsartikel (refereegranskat)abstract
- Background: Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers' perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox's Bazar, Bangladesh and identifies barriers and facilitators in service provision.Method: In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach.Results: The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care.Conclusion: The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers' personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.
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| 7. |
- Rehnström Loi, Ulrika, et al.
(författare)
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Abortion and contraceptive use stigma : a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya.
- 2019
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Ingår i: Sexual and reproductive health matters. - : Informa UK Limited. - 2641-0397. ; 27:3
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Tidskriftsartikel (refereegranskat)abstract
- Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use - the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13-21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = .003 and 50.6%, p = .007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p = .899) or contraceptive use stigma (p = .823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya.
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| 8. |
- Rehnström Loi, Ulrika, et al.
(författare)
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Contraceptive uptake among post-abortion care-seeking women with unplanned or planned pregnancy in western Kenya.
- 2020
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Ingår i: Sexual & Reproductive HealthCare. - : Elsevier BV. - 1877-5756 .- 1877-5764. ; 23
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: To investigate contraceptive uptake among PAC-seeking women reporting either planned pregnancies (PP) or unplanned pregnancies (UP) and to identify factors associated with UP.STUDY DESIGN: This was a sub-study nested in randomised controlled trial (RCT) on women who sought PAC in a low-resource setting in western Kenya. The analysis was based on 807 women who were followed up at 7-10 days and by 472 women at 3 months.MAIN OUTCOME MEASURES: Descriptive statistics and a binary logistic regression model with odds ratios (OR) and 95% confidence intervals (CI) were used.RESULTS: Of the 807 women, 375 (46.3%) reported UP, and 432 (53.3%) PP. Most women, regardless of reported pregnancy intention, agreed to start using contraceptive methods: UP 273 (72.8%) and PP 338 (78.2%), respectively, P = 0.072. Independent factors associated with UP were young age (14-20 years; OR 1.177; 95% CI, 1.045-2.818; P = 0.033), unmarried status (OR 9.149; 95% CI, 5.719-14.638; P < 0.001), nulliparity (OR 1.968; 95% CI, 1.287-3.008; P = 0.002), concealed pregnancy (OR 7.708; 95% CI, 3.299-18.012; P < 0.001) and absence of a partner at the clinic visit (OR 3.174; 95% CI, 2.214-4.552; P < 0.001). At 3-month follow-up, there was no difference in contraceptive use between the UP group (161; 77.4%) and the PP group (193; 73.7%), P = 0.350.CONCLUSION: Contraceptive counselling should be systematically offered to all PAC-seeking women, regardless of their stated pregnancy intention. Adolescents, unmarried women, nulliparous, women with concealed pregnancy and attending the PAC clinic without a partner should be given extra attention by PAC providers offering contraceptive counselling.
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| 9. |
- Sjöström, Susanne, et al.
(författare)
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Medical students are afraid to include abortion in their future practices : in-depth interviews in Maharastra, India
- 2016
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Ingår i: BMC Medical Education. - : Springer Science and Business Media LLC. - 1472-6920. ; 16
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education.METHOD: We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach.RESULTS: The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future.CONCLUSIONS: To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.
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