Preventing unsafe abortion: Achievements and challenges of a global FIGO initiative

Searching for Needles in a Haystack: Exploring Alternative Operational Approaches to Classify the Safety of Induced Abortions Using Respondent-Driven Sampling Data From Two Sub-Saharan African Settings

This study aims to describe the circumstances under which women obtained abortions in two sites, explore more nuanced approaches to classify abortion safety and examine the relationship between safety and self-reported health outcomes. We analyze data on the most recent abortion or only abortion reported by 551 women in Nairobi slums and 479 women in rural Kaya ages 15-49 years within the three years preceding the study, recruited via respondent-driven sampling. Using the most liberal safety classification, there were very few safe abortions (8 percent in Nairobi and 5 percent in Burkina Faso). A significant proportion of women reported using unidentified pills which we hypothesize may be medication abortion. Although a smaller proportion of women with safe abortions reported side effects, more of them reported side effects suggestive of infections and sought care for their symptoms. It is important that we explore and move towards more nuanced global safety classifications that more accurately reflect the risk associated with different methods and can capture women's access to comprehensive abortion care and its impact on their health.

Knowledge level and constructs of the theory of planned behaviour (TPB) to the practice of unsafe abortion among postnatal mothers attending Mkonze health center, Dodoma Region, Tanzania

BACKGROUND

Unsafe abortion is now a global agenda because 45% of all global abortions are unsafe, and 97% are occurring in developing countries. In Tanzania, one million reproductive-aged women face unplanned pregnancies per year, and 39% end up with abortion. About 16% of maternal deaths are reported per year in Tanzania, and unsafe abortion takes the second position. There are several efforts to prevent and intervene unsafe abortions, such as equipping healthcare facilities across all levels of healthcare, approval of Misoprostol use, establishment of comprehensive post-abortion care (PAC), revising policy guidelines and standards, provision of emergency contraceptives, and capacity building of healthcare providers. There is little documentation about how the constructs of the theory of planned behaviour, knowledge, and sociodemographics influence the practice of abortion.

OBJECTIVES

To assess the association of knowledge level, sociodemographic characteristics, and constructs of the theory of planned behaviour (TPB) to the practice of unsafe abortion among postnatal mothers at Mkonze Health Center in the Dodoma region.

METHODOLOGY

It is an analytical cross-sectional study design conducted in Dodoma-Tanzania and involved 206 postnatal women. A validated questionnaire was used and analysis was performed in the Statistical Package for the Social Sciences (SPSS), through descriptive and inferential statistics.

RESULTS

The practice of unsafe abortion in the current study is 28/206 (13.6%), influenced bytheir lower educational level and being single women. It was found that the majority had adequate knowledge of unsafe abortion 129 (62.6%), positive attitude 130 (63.1%), good subjective norms 113 (54.9%), and positive perceived behavioral control111 (53.9%). Knowledge, attitude, subjective norms, and perceived behavioral control were not significantly associated with the practice of unsafe abortion.

CONCLUSION

The majority of the respondents had high knowledge, attitudes, subjective norms, and perceived behavior control on unsafe abortion. This is an indicator that the implemented initiatives are effective. Maintaining the ongoing effort and improving strategies are promising to mitigate the burden of unsafe abortion. Future research needs to find out hidden factors associated with attitude and how health beliefs might influence someone's attitude towards unsafe abortion.

Determinants of Health Care Providers' Attitudes Toward Safe Abortion Care in Ethiopia: A Systematic Review and Meta-Analysis

Background

Unsafe abortion is a serious reproductive health problem in developing countries including Ethiopia. The attitude of healthcare providers toward abortion is one of contributing factors to unsafe abortion. This study aimed to determine the pooled effect of healthcare workers' attitudes toward safe abortion care and its determinants factors in Ethiopia.

Methods

Search engines such as Scopus, CINAHL, EMBASE, PubMed, Web of Science, and CAB Abstracts were used to find published studies where as Google and Google Scholar were used to find unpublished research. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. The analysis was performed using STATA 14 and the random-effects model was used to calculate the odds ratios of medical professionals' attitudes regarding safe abortion services. Study heterogeneity was assessed by using I2 and P-values. To evaluate the stability of pooled values to outliers and publication bias, respectively, sensitivity analysis and funnel plot were also performed.

Results

A total of 15 published and unpublished articles with a sample size of 4060 were incorporated in this Review. The overall pooled prevalence of this study was 56% (95% CI: 45-67). Sex of participants (AOR: 2.37; 95% CI: 1.57, 3.58), having training (AOR: 2.86; 95% CI: 1.58, 5.17), Professional type (AOR: 1.55; 95% CI: 1.04, 4.46), and knowledge of abortion law (AOR:2.26; 95% CI: 1.14, 4.46) were the determinants factors that significantly associated with health care workers' attitude toward safe abortion care. Sensitivity analysis shows that the pooled odds ratios were consistently stable throughout all meta-analyses, and the funnel plot shows no evidence of publication bias.

Conclusion

Half of health care providers sampled among the pooled studies have favorable attitudes toward abortion services in Ethiopia; which could hamper women's access to safe abortion care. Sex, training, type of profession, and knowing abortion law were determinants of health care workers' attitudes toward safe abortion services. Stakeholders should emphasize improving the attitude of healthcare workers toward safe abortion care which has a vital role in reducing maternal mortality. Moreover, working on modifiable factors like training, assigning personnel whose professions align with the service, and updating care providers about abortion law is also the essential key point to improve their intentions to deliver the services.

Dantas PB, Trabach CB, Junqueira AA, Nunes CC, Baccaro LF. Analysis of uterine evacuation methods in postabortion care after implementation of a surveillance network (CLAP MUSA-Network) at a university hospital

BACKGROUND

Management of uterine evacuation is essential for increasing safe abortion care. Monitoring through surveillance systems tracks changes in clinical practice and provides information to improve equity in abortion care quality.

OBJECTIVE

This study aimed to evaluate the frequency of manual vacuum aspiration (MVA) and medical abortion (MA), and identify the factors associated with each uterine evacuation method after surveillance network installation at a Brazilian hospital.

METHODS

This cross-sectional study included women admitted for abortion or miscarriage to the University of Campinas Women's Hospital, Brazil, between July 2017 and November 2020. The dependent variables were the use of MVA and MA with misoprostol. The independent variables were the patients' clinical and sociodemographic data. The Cochran-Armitage, chi-square, and Mann-Whitney U tests, as well as multiple logistic regression analysis, were used to compare uterine evacuation methods.

RESULTS

We enrolled 474 women in the study, 91.35% of whom underwent uterine evacuation via uterine curettage (78.75%), MVA (9.46%), or MA (11.54%). MVA use increased during the study period (Z = 9.85, p < 0.001). Admission in 2020 (odds ratio [OR] 64.22; 95% confidence interval [CI] 3.79-1086.69) and lower gestational age (OR 0.837; 95% CI 0.724-0.967) were independently associated with MVA, whereas the only factor independently associated with MA was a higher education level (OR 2.66; 95% CI 1.30-5.46).

CONCLUSION

MVA use increased following the installation of a surveillance network for good clinical practice. Being part of a network that encourages the use of evidence-based methods provides an opportunity for healthcare facilities to increase access to safe abortions.

Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda

BACKGROUND

From 2018, the International Federation of Gynecologists and Obstetricians (FIGO) implemented the Advocating Safe Abortion project to support national obstetrics and gynecology (Obs/gyn) societies from ten member countries to become leaders of Sexual and Reproductive Health and Rights (SRHR). We share experiences and lessons learnt about using value clarification and attitude transformation (VCAT) and abortion harm reduction (AHR) as strategies for our advocacy engagements.

METHODS

The advocacy goal of ending abortion-related deaths followed predefined pathways from an extensive needs assessment prior to the project. These pathways were strengthening capacity of the Obs/gyn society as safe abortion advocates; establishing a vibrant network of partners; transforming social and gender norms; raising awareness of the legal and policy environment regarding abortion, and promoting the generation and use abortion data for evidence-informed policy and practice. Our advocacy targeted multiple stakeholders including media, policy makers judicio-legal, political and religious leaders, health workers and the public.

RESULTS

During each engagement, facilitators required audiences to identify what roles they can play along the continuum of strategies that can reduce maternal death from abortion complications. The audiences acknowledged abortion complications as a major problem in Uganda. Among the root causes for the abortion context, audiences noted absence of an enabling environment for abortion care, which was characterized by low awareness about the abortion laws and policy, restricted abortion laws, cultural and religious beliefs, poor quality of abortion care services and abortion stigma.

CONCLUSION

VCAT and AHR were critical in enabling us to develop appropriate messages for different stakeholders. Audiences were able to recognize the abortion context, distinguish between assumptions, myths and realities surrounding unwanted pregnancy and abortion; recognize imperative to address conflict between personal and professional values, and identify different roles and values which inform empathetic attitudes and behaviors that mitigate abortion harms. The five pathways of the theory of change reinforced each other. Using the AHR model, we delineate strategies and activities which stakeholders could use to end abortion deaths. VCAT enables critical reflection of views, beliefs and values versus professional obligations and responsibilities, and promotes active attitude and behavior change and commitment to end abortion-related deaths.

Evaluating women’s acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians: a mixed methods study

Background

Studies evaluating task sharing in postabortion care have mainly focused on women in first trimester and many lack a qualitative component. We aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients’ lived treatment experiences in Uganda.

Methods

Our mixed methods study combined 1140 structured interview data from a randomized controlled equivalence trial and in-depth interviews (n = 28) among women managed with misoprostol for second trimester incomplete abortion at 14 public health facilities in Uganda. Acceptability, our main outcome, was measured at the 14-day follow-up visit using a structured questionnaire as a composite variable of: 1) treatment experience (as expected/ better than expected/ worse than expected), and 2) satisfaction - if patient would recommend the treatment to a friend or choose the method again. We used generalized mixed effects models to obtain the risk difference in acceptable post abortion care between midwife and physician groups. We used inductive content analysis for qualitative data.

Results

From 14th August 2018 to 16th November 2021, we assessed 7190 women for eligibility and randomized 1191 (593 to midwife and 598 to physician). We successfully followed up 1140 women and 1071 (94%) found the treatment acceptable. The adjusted risk difference was 1.2% (95% CI, − 1.2 to 3.6%) between the two groups, and within our predefined equivalence range of − 5 to + 5%. Treatment success and feeling calm and safe after treatment enhanced acceptability while experience of side effects and worrying bleeding patterns reduced satisfaction.

Conclusions

Misoprostol treatment of uncomplicated second trimester incomplete abortion was equally and highly acceptable to women when care was provided by midwives compared with physicians. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient’s access to postabortion care services.

Trial registration

ClinicalTrials.gov NCT03622073.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-02027-y.

Approximately 9.6% of abortion-related deaths occur in Sub-Saharan Africa. These deaths can be prevented if unintended pregnancies are avoided, women can access safe abortions within the expectations of the country’s laws, and post abortion care (PAC) services are provided equitably. Previous research shows that women with abortion complications in the first trimester of pregnancy can be treated with misoprostol by either midwives or physicians. This sharing of tasks between the midwives and physicians is safe, effective, and acceptable. However, there is a gap in evidence on task sharing in the second trimester. To check practicability of task sharing in second trimester, we aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients’ lived treatment experiences. Our study therefore combined quantitative and qualitative approaches. Women’s acceptability of misoprostol treatment for incomplete second trimester abortion was found to be equally acceptable when provided by midwives compared with physicians. Treatment success, feeling calm and safe after treatment increased acceptability, while experience of side effects and worrying bleeding patterns reduced satisfaction. Counselling of women may address some of these problems since it provides reassurance and reduces anxiety. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient’s access to PAC services.

Knowledge, attitude and factors associated with induced abortion among female students ‘of Private Colleges in Ambo town, Oromia regional state, Ethiopia: a cross-sectional study

Background

Around 73 million induced abortions take place worldwide each year. Six out of 10 (61%) of all unintended pregnancies, and 3 out of 10 (29%) of all pregnancies, end in induced abortion. In Africa, nearly half of all abortions occur under the least safe circumstances. In Ethiopia 35% of women obtaining induced abortions service. Therefore, thisstudy aims to assess knowledge, attitude, and associated factors towards induced abortion serviceamong female students of private Colleges in Ambo town, Ethiopia, 2022.

Methods

An Institution-based cross-sectional study was conducted from January 15, 2022, to February 15, 2022, among college students in Ambo, Ethiopia. Data were collected from 631 female students using semi-structured self-administered questionnaires by a systematic sampling method. We collected data on demographics, Institutional factors: facility policy and regulation, sexual experience, knowledge, and attitude. Bivariable and multivariable logistic regression analyses were done to identify the association of dependent and independent variables using SPSS, version 26, at 95% of confidence interval by adjusting for confounding factors. Finally, variables with p-value ≤ 0.05 were taken as factors associated.

Results

All the participants gave their responses.Among the participants 279 (44.2) have good knowledge while the majority 352 (55.8%) of the students had poor knowledge about induced abortion. Age [AOR = 4.64, 95% CI (2.95,7.30)], Marital status [AOR = 5.24, 95% CI (3.16, 8.69)], religion [AOR = 0.48, 95% CI (0.26,0.81)], Year of study [AOR = 4.51, 95% CI (2.88,7.08)], Monthly earn/income [AOR = 2.07, 95% (CI 1.40,3.07)], Ever had sex [AOR = 1.92, 95% CI (1.26,2.92)] and urban residence [AOR = 1.87, 95% CI (1.26, 4.35)] were factors associated with knowledge of students towards induced abortion. Regarding attitude, 377 (59.7%) of students had good attitude towards induced abortion. Marital status [AOR = 2.30, 95% CI (1.30, 4.0)], and Religion [AOR = 0.47, 95% CI (0.10, 2.23)] were factors significantly associated with attitude towards induced abortion.

Conclusion

More than half of the participants have poor knowledge while majority of the students have a good attitude toward induced abortion. Since majority of the students (55.8%) have poor knowledge about induced abortion: health education, short course training, panel discussions and communication programs for youth on induction of abortion services is crucial.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda

Background

To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda.

Methods

Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13–18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 μg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was –5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073.

Findings

Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was –2·3% (95% CI –4·4 to –0·3), and within our predefined equivalence range (–5% to 5%). Two women in the midwife group received blood transfusion.

Interpretation

Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care.

Funding

Swedish Research Council and THRiVE-2.

Exploring health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion in Central Uganda

Introduction

Women living in low- and middle-income countries still have limited access to quality second trimester post abortion care. We aim to explore health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion.

Methods

This qualitative study used the phenomenology approach. We conducted 48 in-depth interviews for doctors and midwives at 14 public health facilities in central Uganda using a flexible interview guide. We used inductive content analysis and made code frequencies based on health care provider cadre, and health facility level and then abstracted themes from categories.

Results

Well trained midwives were perceived as competent to manage second trimester post abortion care stable patients, however doctor’s supervision in case of complications was considered important. Sometimes, midwives were seen as offering better care than doctors given their stronger presence in the facilities. Misoprostol received unanimous support and viewed as: safe, effective, cheap, convenient, readily available, maintained patient privacy, and saved resources. Challenges faced included: side effects, prolonged hospital stay, treatment failure, inclination to surgical evacuation, heavy work load, inadequate space, lack of medical commodities, frequent staff rotations which affects the quality of patient care. To address these challenges, respondents coped by: giving patients psychological support, analgesics, close patient monitoring, staff mentorship, commitment to work, team work and patient involvement in care.

Conclusion

Misoprostol is perceived as an ideal uterine evacuation method for second trimester post abortion care of uncomplicated patients and trained midwives are considered competent managing these patients in a health facility setting with a back-up of a doctor. Health care providers require institutional and policy environment support for improved service delivery.

[Unsafe abortions in the State of Rio de Janeiro, Brazil: magnitude and time trend from 2008 to 2017]

Data on unsafe abortions are scarce, and estimates based on hospitalizations have pointed to a decline in recent years. The study aimed to analyze the time trend in unsafe abortions in the State of Rio de Janeiro, Brazil, from 2008 to 2017. We used secondary data on hospitalizations in the Brazilian Unified National Health System (SUS) due to complications of abortion in childbearing-age women (CAW) 15 to 44 years of age. We applied indirect estimation with a correction factor based on national and state data. We calculated the unsafe abortion rate per CAW (UAR-CAW), ratio of unsafe abortions per live births (RUA-LB), according to age bracket. We also calculated new indicators: spontaneous abortion rate (SAR) and unspecified abortion rate (USAR) per CAW; ratio of spontaneous abortions (RSA) and ratio of unspecified abortions (RUSA) per live births, independently of age. Time trend was calculated by Joinpoint regression, calculating the annual percent change (APC) and 95% confidence intervals (95%CI). The women that most induced abortions were 20 to 24 years of age, with UAR of 8 per 1,000. Pregnancies that ended in unsafe abortion were most frequent in the 40-44-year bracket: UAR of 16 to 20 per 100 live births. Adolescents showed a reduction in UAR from 2015 to 2017 (APC = -10; 95%CI: -18.2; -1.1), while there was an increase in women 40-44 years of age from 2008 to 2017 (APC = 2.2; 95%CI 0.5 to 4.0). The other age brackets and the indicator UAR-LB showed stability. SAR (APC = -3.5; 95%CI: -5.9; -1.0), and RSA (APC = -3.8; 95%CI: -6.3; -1.2) decreased, while USAR (APC = 6.6; 95%CI: 1.7; 11.8) and RUSA (APC = 6.4; 95%CI: 1.6; 11.3) increased during the period. The magnitude and time trend of unsafe abortions in the State of Rio de Janeiro differed according to age bracket and ICD-10 code.

Post-abortion care services at Red Sea State - Sudan

Background

Although there are safe and effective methods of abortion, unsafe abortions still widely spread, mainly in underdeveloped countries.

Objective

Study of post abortion care services at Red Sea State to address rate and utilization of post-abortion care package.

Methods

This is a descriptive (observational hospital-based study), conducted at Port Sudan Maternity hospital (May 2018-May 2019). The sample included all patients with inevitable and incomplete miscarriage.

Results

The total admissions to emergency in gynaecological department during the study period was 9525 cases, of them 1077 cases of abortion, hence the rate was 11.3%. Spontaneous onset occurred in 631 (58.6%) and induced in 446 (41.4%). Surprisingly very few surgical evacuations done in 2 (0.2%). 710 (66.1%) evacuated by Misoprostol and MVA done for 362 (33.7%). Patients who received family planning and counseling were 223 (20.7%).

Conclusion

in conclusion the rate of abortion was 11.3%, high incidence of induced abortion and high non-surgical evacuation. Utilization of care package is reasonable.

Post-abortion contraception before hospital discharge after installation of a surveillance network in Brazil

OBJECTIVE

To evaluate the use of contraception soon after abortion, ectopic, or molar pregnancy following the establishment of a surveillance network (MUSA).

METHODS

A cross-sectional study of women admitted for abortion, or ectopic or molar pregnancy at UNICAMP Women's Hospital (part of the MUSA Network), Campinas, Brazil, between July 2017 and August 2019. Clinical and sociodemographic data were compared between women who initiated contraception before discharge and those who did not by using a Cochran-Armitage test and multiple logistic regression.

RESULTS

Overall, 382 women were enrolled (mean ± SD age, 29.6 ± 7.4 years). Most women (287, 75.2%) had abortions, and 146 (38.2%) initiated contraception before hospital discharge. The most common contraceptives were injectables (75, 51.4%) followed by pills (65, 44.5%). Use of contraception increased during the study period (Z=3.69, P<0.01), mostly due to injectables (Z=3.84, P<0.01). Factors independently associated with contraceptive initiation were admission in 2019 (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.36-5.17) and not having an abortion for legal reasons (OR, 3.54; 95% CI, 1.30-9.62).

CONCLUSION

Implementation of a surveillance network optimized the health service and quality of care. There was an increase in contraception use and a vulnerable population was identified.