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Frisendahl C, Looft-Trägårdh E, Cleeve A, Atuhairwe S, Larsson EC, Kakaire O, Kayiga H, Aronsson A, Kihara A, Temmerman M, Klingberg Allvin M, Byamugisha J, Gemzell Danielsson K. Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return. Glob Health Action 2024; 17:2353957. [PMID: 38826144 PMCID: PMC11149584 DOI: 10.1080/16549716.2024.2353957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/07/2024] [Indexed: 06/04/2024] Open
Abstract
As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.
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Affiliation(s)
- Caroline Frisendahl
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Emelie Looft-Trägårdh
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Amanda Cleeve
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Susan Atuhairwe
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Elin C. Larsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Othman Kakaire
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Herbert Kayiga
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Annette Aronsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anne Kihara
- Department of Obstetrics and Gynecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Marleen Temmerman
- Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marie Klingberg Allvin
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Maregn RT, Bourret K, Egal JA, Esse A, Mattison C, Klingberg-Allvin M. Qualitative study of the roles of midwives in the provision of sexual and reproductive healthcare services in the Somaliland health system. BMJ Open 2023; 13:e067315. [PMID: 36921954 PMCID: PMC10030797 DOI: 10.1136/bmjopen-2022-067315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVES To explore midwives' perspectives in providing sexual reproductive healthcare services in the Somaliland health system. METHODS An exploratory qualitative design using focus group discussions (n=6) was used. The study was conducted in the capital of Somaliland, Hargeisa, at six maternal and child healthcare centres that provide sexual and reproductive healthcare (SRH) services. Qualified midwives (n=44) who had been working in the maternal and child health centres for a minimum of 1 year were recruited to participate, and only one did not participate due to illness. RESULTS The results showed that Somaliland midwives face multiple challenges from a lack of formal arrangements, primarily written guidelines and policies, that explicitly define their role as healthcare professionals, which impact the quality of care they provide. They also reported feeling unsafe when practising according to their professional scope of practice due to challenging cultural norms, customary traditions and Somaliland's legal system. Finally, the midwives called for support, including training, institutional protection and psychological support, to enhance their ability and fulfil their role in SRH services in Somaliland. CONCLUSION Midwives are essential to the provision of equitable SRH services to women and girls, yet are not fully supported by policies, laws or institutions, often living in fear of the consequences of their behaviours. Our research highlights the importance of understanding the context of Somaliland midwifery in order to better support the development of the midwifery workforce, stronger governance structures and midwifery leadership. Appropriately addressing these challenges faced by midwives can better sustain the profession and help to improve the quality of care provided to women and girls and ultimately enhance their reproductive health outcomes.
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Affiliation(s)
| | - Kirsty Bourret
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Jama Ali Egal
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Faculty of Nursing and Midwifery, College of Medicine and Health Sciences, University of Hargeisa, Hargeisa, Somalia
| | - Amina Esse
- Faculty of Nursing and Midwifery, College of Medicine and Health Sciences, University of Hargeisa, Hargeisa, Somalia
| | - Cristina Mattison
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Marie Klingberg-Allvin
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden
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Liu Y, Lv W. The diagnostic value of transvaginal color Doppler ultrasonography plus serum β-HCG dynamic monitoring in intrauterine residue after medical abortion. Medicine (Baltimore) 2023; 102:e31217. [PMID: 36749252 PMCID: PMC9901960 DOI: 10.1097/md.0000000000031217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
To probe the diagnostic value of transvaginal color Doppler ultrasonography plus serum β-human chorionic gonadotropin (β-HCG) dynamic monitoring in intrauterine residue after medical abortion.In total, 200 pregnant women undergoing medical abortion in our institution from January 2017 to December 2019 were picked, and assigned to either group A (n = 75, with residue) or group B (n = 125, without residue). We detected serum β-HCG, progesterone (P), follicle stimulating estrogen (FSH) levels and ultrasonic indicators endometrial thickness (ET), peak systolic velocity (PSV), resistance index (RI) values, dissected correlation of indicators using logistic linear regression analysis, and prospected the diagnostic value of relevant indicators in intrauterine residue after medical abortion utilizingreceiver operating characteristic curve.At 7 days after abortion (T3), total vaginal bleeding and visual analogue scalescore in group A were saliently higher in contrast to group B ( P < .05). At 72 hours after abortion (T2) and T3, serum β-HCG, P and FSH levels declined strikingly in both groups, but group B held plainly higher decrease rate than group A ( P HC.05). At T3, ET and PSV levels in both groups considerably waned, whereas RI levels notedly waxed, and group B owned markedly higher decrease/increase than group A ( P wa.05). At T3, serum β-HCG in group A possessed positive association with serum P, FSH, intrauterine ET, PSV levels separately ( P HC.05), whereas negative link with RI levels ( P , .05). The specificity and sensitivity of β-HCG, P, FSH, β-HCG/ET, β-HCG/PSV and β-HCG/RI in the diagnosis of intrauterine residue after medical abortion were high ( P < .05).Serum β-HCG dynamic monitoring plus transvaginal color Doppler ultrasonography is of great value in diagnosing intrauterine residue after medical abortion. Serum β-HCG, P, FSH levels can be combined with the results of intrauterine ET, PSV, RI values, so as to boost the diagnostic accuracy of the intrauterine residue after medical abortion.
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Affiliation(s)
- Yanbo Liu
- Department of Gynecology, Litongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Wen Lv
- Department of Gynecology, Litongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, China
- * Correspondence: Wen Lv, Department of Gynecology, Litongde Hospital of Zhejiang Province, 234 Gucui Road, Xihu District, Hangzhou, Zhejiang 310012, China (e-mail: )
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Magreta Chakhame B, Darj E, Mwapasa M, Kafulafula U, Chiudzu G, Maluwa A, Malata A, Odland JØ, Odland ML. Effectiveness of a training intervention in increasing the use of misoprostol in postabortion care in Malawi: a quasi-experimental study. BMJ Open 2022; 12:e061886. [PMID: 36517095 PMCID: PMC9756167 DOI: 10.1136/bmjopen-2022-061886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The study was conducted to determine effectiveness of a training intervention in increasing use of misoprostol in management of incomplete abortions. DESIGN A quasi-experimental study with training intervention on use of misoprostol in treatment of incomplete abortion. SETTING Five secondary-level public hospitals in Malawi, one in urban and four in semiurban settings. Three intervention and two control sites. PARTICIPANTS Records of women treated for first-trimester incomplete abortion from March to May 2020 (baseline) and April to June 2021 (endline). Clinical data were collected from 865 records, 421 before and 444 after the intervention in all study sites. INTERVENTION Three-hour theoretical training sessions for 81 healthcare workers were conducted in July 2020 at the three intervention sites. PRIMARY AND SECONDARY OUTCOME MEASURES Proportion of women with incomplete abortion treated with misoprostol before and after the intervention. The proportion of women treated with sharp curettage at the study sites. RESULTS At the intervention sites, there was a significant increase in use of misoprostol from 22.8% (95% CI 17.9% to 28.0%) to 35.9% (95% CI 30.5% to 41.6%) and significant reduction in use of sharp curettage from 48.1% (95% CI 41.9% to 54.3%) to 39.4% (95% CI 35.3% to 42.6%) p<0.01 at baseline and endline, respectively. The use of misoprostol was significantly higher at the intervention sites with OR of 5.02 (95% CI 1.7 to 14.7) p<0.05 compared with control sites at the endline in multivariable models, and there was a difference in the difference of 14.4% ((95% CI 10.4% to 18.2%) p<0.001) between the intervention and control sites after the intervention. CONCLUSIONS A training intervention effectively increased the use of misoprostol in the treatment of incomplete abortions. Increasing misoprostol use will make treatment of incomplete abortion cheaper, easier and more easily accessible. Making quality postabortion care accessible to more women may reduce maternal morbidity and mortality. Further training interventions are recommended.
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Affiliation(s)
- Bertha Magreta Chakhame
- School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Elisabeth Darj
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Mphatso Mwapasa
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
| | - Ursula Kafulafula
- School of Maternal, Neonatal and Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Grace Chiudzu
- Department of Obstetrics and Gynecology, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Alfred Maluwa
- Department of Research and Postgraduate Outreach, Malawi University of Science and Technology, Thyolo, Malawi
| | - Address Malata
- Department of Research and Postgraduate Outreach, Malawi University of Science and Technology, Thyolo, Malawi
| | - Jon Øyvind Odland
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
- Faculty of Biosciences and Aquaculture, Nord University, Bodø, Norway
- Department of Public Health, University of Pretoria, Pretoria, South Africa
| | - Maria Lisa Odland
- Department of Public Health and Nursing, The Norwegian University of Science and Technology, Trondheim, Norway
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, St. Olav's Hospital, Trondheim, Norway
- Malawi-Liverpool-Wellcome Trust Research Institute, Blantyre, Malawi
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Wagenheim CA, Savosnick H, Chakhame BM, Darj E, Kafulafula UK, Maluwa A, Odland JØ, Odland ML. Health care providers’ perceptions of using misoprostol in the treatment of incomplete abortion in Malawi. BMC Health Serv Res 2022; 22:1471. [DOI: 10.1186/s12913-022-08878-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 11/23/2022] [Indexed: 12/04/2022] Open
Abstract
Abstract
Background
In Malawi, abortion is only legal to save a pregnant woman’s life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers’ perceptions on this matter are crucial.
Methods
A qualitative approach was used to explore health care providers’ perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using ‘Systematic Text Condensation’.
Results
The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method.
Conclusion
Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice.
Plain English Summary
Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use.
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Atuhairwe S, Byamugisha J, Kakaire O, Hanson C, Cleeve A, Klingberg-Allvin M, Tumwesigye NM, Gemzell-Danielsson K. 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. Lancet Glob Health 2022; 10:e1505-e1513. [PMID: 36030801 PMCID: PMC9605879 DOI: 10.1016/s2214-109x(22)00312-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/23/2022] [Accepted: 06/28/2022] [Indexed: 12/04/2022]
Abstract
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.
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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Amanda Cleeve
- Department of Women and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Nazarius Mbona Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
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Abstract
BACKGROUND Medical abortion became an alternative method of pregnancy termination following the development of prostaglandins and antiprogesterone in the 1970s and 1980s. Recently, synthesis inhibitors of oestrogen (such as letrozole) have also been used to enhance efficacy. The most widely researched drugs are prostaglandins (such as misoprostol, which has a strong uterotonic effect), mifepristone, mifepristone with prostaglandins, and letrozole with prostaglandins. More evidence is needed to identify the best dosage, regimen, and route of administration to optimise patient outcomes. This is an update of a review last published in 2011. OBJECTIVES To compare the effectiveness and side effects of different medical methods for first trimester abortion. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Global Health, and LILACs on 28 February 2021. We also searched Clinicaltrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform, and reference lists of retrieved papers. SELECTION CRITERIA We considered randomised controlled trials (RCTs) that compared different medical methods for abortion before the 12th week of gestation. The primary outcome is failure to achieve complete abortion. Secondary outcomes are mortality, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the method. DATA COLLECTION AND ANALYSIS Two review authors independently selected and evaluated studies for inclusion, and assessed the risk of bias. We processed data using Review Manager 5 software. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 99 studies in the review (58 from the original review and 41 new studies). 1. Combined regimen mifepristone/prostaglandin Mifepristone dose: high-dose (600 mg) compared to low-dose (200 mg) mifepristone probably has similar effectiveness in achieving complete abortion (RR 1.07, 95% CI 0.87 to 1.33; I2 = 0%; 4 RCTs, 3494 women; moderate-certainty evidence). Prostaglandin dose: 800 µg misoprostol probably reduces abortion failure compared to 400 µg (RR 0.63, 95% CI 0.51 to 0.78; I2= 0%; 3 RCTs, 4424 women; moderate-certainty evidence). Prostaglandin timing: misoprostol administered on day one probably achieves more success on complete abortion than on day three (RR 1.94, 95% CI 1.05 to 3.58; 1489 women; 1 RCT; moderate-certainty evidence). Administration strategy: there may be no difference in failure of complete abortion with self-administration at home compared with hospital administration (RR 1.63, 95% CI 0.68 to 3.94; I2 = 84%; 2263 women; 4 RCTs; low-certainty evidence), but failure may be higher when administered by nurses in hospital compared to by doctors in hospital (RR 2.69, 95% CI 1.39 to 5.22; I2 = 66%; 3 RCTs, 3056 women; low-certainty evidence). Administration route: oral misoprostol probably leads to more failures than the vaginal route (RR 2.38, 95% CI 1.46 to 3.87; I2 = 39%; 3 RCTs, 1704 women; moderate-certainty evidence) and may be associated with more frequent side effects such as nausea (RR 1.14, 95% CI 1.03 to 1.26; I2 = 0%; 2 RCTs, 1380 women; low-certainty evidence) and diarrhoea (RR 1.80 95% CI 1.49 to 2.17; I2 = 0%; 2 RCTs, 1379 women). Compared with the vaginal route, complete abortion failure is probably lower with sublingual (RR 0.68, 95% CI 0.22 to 2.11; I2 = 59%; 2 RCTs, 3229 women; moderate-certainty evidence) and may be lower with buccal administration (RR 0.71, 95% CI 0.34 to 1.46; I2 = 0%; 2 RCTs, 479 women; low-certainty evidence), but sublingual or buccal routes may lead to more side effects. Women may experience more vomiting with sublingual compared to buccal administration (RR 1.33, 95% CI 1.01 to 1.77; low-certainty evidence). 2. Mifepristone alone versus combined regimen The efficacy of mifepristone alone in achieving complete abortion compared to combined mifepristone/prostaglandin up to 12 weeks is unclear (RR of failure 3.25, 95% CI 0.81 to 13.09; I2 = 83%; 3 RCTs, 273 women; very low-certainty evidence). 3. Prostaglandin alone versus combined regimen Nineteen studies compared prostaglandin alone to a combined regimen (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate). Compared to any of the combination regimens, misoprostol alone may increase the risk for failure to achieve complete abortion (RR of failure 2.39, 95% CI 1.89 to 3.02; I2 = 64%; 18 RCTs, 3471 women; low-certainty evidence), and with more diarrhoea. 4. Prostaglandin alone (route of administration) Oral misoprostol alone may lead to more failures in complete abortion than the vaginal route (RR 3.68, 95% CI 1.56 to 8.71, 2 RCTs, 216 women; low-certainty evidence). Failure to achieve complete abortion may be slightly reduced with sublingual compared with vaginal (RR 0.69, 95% CI 0.37 to 1.28; I2 = 87%; 5 RCTs, 2705 women; low-certainty evidence) and oral administration (RR 0.58, 95% CI 0.11 to 2.99; I2 = 66%; 2 RCTs, 173 women). Failure to achieve complete abortion may be similar or slightly higher with sublingual administration compared to buccal administration (RR 1.11, 95% CI 0.71 to 1.74; 1 study, 401 women). AUTHORS' CONCLUSIONS Safe and effective medical abortion methods are available. Combined regimens (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate) may be more effective than single agents (prostaglandin alone or mifepristone alone). In the combined regimen, the dose of mifepristone can probably be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is probably more effective than oral administration, and may have fewer side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all studies were conducted in settings with good access to emergency services, which may limit the generalisability of these results.
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Affiliation(s)
- Jing Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Reproductive Endocrinology and Regulation Laboratory, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kunyan Zhou
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Reproductive Endocrinology and Regulation Laboratory, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Dan Shan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Reproductive Endocrinology and Regulation Laboratory, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiaoyan Luo
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Reproductive Endocrinology and Regulation Laboratory, West China Second University Hospital, Sichuan University, Chengdu, China
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Exploring health care providers’ experiences of and perceptions towards the use of misoprostol for management of second trimester incomplete abortion in Central Uganda. PLoS One 2022; 17:e0268812. [PMID: 35587492 PMCID: PMC9119526 DOI: 10.1371/journal.pone.0268812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/09/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Atuhairwe S, Gemzell-Danielsson K, Byamugisha J, Kaharuza F, Tumwesigye NM, Hanson C. Abortion-related near-miss morbidity and mortality in 43 health facilities with differences in readiness to provide abortion care in Uganda. BMJ Glob Health 2021; 6:bmjgh-2020-003274. [PMID: 33547174 PMCID: PMC7871269 DOI: 10.1136/bmjgh-2020-003274] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. Methods This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016–2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. Results Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. Conclusions Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.
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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda .,Reproductive Endocrinology and Infertility, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University CHS, Kampala, Uganda
| | - Frank Kaharuza
- Association of Obstetricians and Gynaecologists of Uganda, Kampala, Uganda
| | | | - Claudia Hanson
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Dept of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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Kristiansen MB, Shayo BC, Philemon R, Khan KS, Rasch V, Linde DS. Medical management of induced and incomplete first-trimester abortion by non-physicians in low- and middle-income countries: A systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2021; 100:718-726. [PMID: 33724458 DOI: 10.1111/aogs.14134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Unsafe abortion is the cause of a substantial number of maternal mortalities and morbidities globally, but specifically in low- and middle-income countries. Medical abortion methods provided by non-physicians may be a way to reduce the burden of unsafe abortions. Currently, only one systematic review comparing non-physicians with physicians for medical abortion exists. However, the review does not have any setting restrictions and newer evidence has since been published. Therefore, this review aims to evaluate the effectiveness, acceptability, and safety of first-trimester abortion managed by non-physicians compared with physicians in low- and middle-income countries. MATERIAL AND METHODS The databases PubMed, Cochrane Library, Global Health Library, and EMBASE were searched using a structured search strategy. Further, the trial registries clinicaltrials.gov and The International Clinical Trial Registry Platform were searched for published and unpublished trials. Randomized controlled trials comparing provision of medical abortion by non-physicians with that by physicians in low- or middle-income countries were included. Risk of bias was assessed using the Cochrane Risk of Bias tool. Trials that reported effect estimates on the effectiveness of medical methods on complete abortion were included in the meta-analysis. The protocol was prospectively registered in the PROSPERO database, ID: CRD42020176811. RESULTS Six papers from four different randomized controlled trials with a total of 4021 participants were included. Two of the four included trials were assessed to have overall low risk of bias. Four papers had outcome data on complete abortion and were included in the meta-analyses. Medical management of first-trimester abortion and medical treatment of incomplete abortion were found to be equally effective when provided by a non-physician as when provided by a physician (risk ratio 1.00; 95% CI 0.99-1.01). Further, the treatment was equally safe, and women were equally satisfied when a non-physician provided the treatment compared with a physician. CONCLUSIONS Provision of medical abortion or medical treatment for incomplete abortion in the first trimester is equally effective, safe, and acceptable when provided by non-physicians compared with physicians in low- and middle-income countries. We recommend that the task of providing medical abortion and medical treatment for incomplete abortion in low- and middle-income countries should be shared with non-physicians.
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Affiliation(s)
| | - Benjamin C Shayo
- Kilimanjaro Christian Medical Center, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Rune Philemon
- Kilimanjaro Christian Medical Center, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Khalid Saeed Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain.,CIBER of Epidemiology and Public Health (CIBERESP), Granada, Spain
| | - Vibeke Rasch
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark
| | - Ditte Søndergaard Linde
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Obstetrics and Gynecology, Odense University Hospital, Odense, Denmark.,Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
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12
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Endler M, Cleeve A, Sääv I, Gemzell-Danielsson K. How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events. Int J Gynaecol Obstet 2021; 150 Suppl 1:34-42. [PMID: 33219992 PMCID: PMC7539959 DOI: 10.1002/ijgo.13003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.
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Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Sääv
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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13
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Simpson JL, Rechitsky S. Preimplantation genetic testing to reduce preterm births in assisted reproductive technology. Int J Gynaecol Obstet 2020; 150:34-40. [PMID: 32524593 DOI: 10.1002/ijgo.13192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/06/2020] [Indexed: 11/12/2022]
Abstract
The 10% rate of preterm birth rate worldwide has not been proved amenable to reduction. Avoiding multiple embryo transfer in assisted reproductive technologies (ART) using in vitro fertilization is one unassailable method. Preimplantation genetic testing (PGT) to select only a single euploid embryo for transfer is one unequivocal way, maintaining 50%-60% pregnancy rates while avoiding twins. Contemporary methodology entails trophectoderm biopsy of a 5-6-day blastocyst, and cryopreservation of biopsied embryos while awaiting analysis by next generation sequencing. Embryo biopsy is safe, analytic validity for chromosomal analysis high, and global access to PGT high.
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Affiliation(s)
- Joe L Simpson
- Department of Obstetrics and Gynecology, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Department of Human and Molecular Genetics, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Reproductive Genetic Innovations, Northbrook, IL, USA
| | - Svetlana Rechitsky
- Department of Human and Molecular Genetics, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Reproductive Genetic Innovations, Northbrook, IL, USA
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Souizi B, Akrami R, Borzoee F, Sahebkar M. Comparison of the efficacy of sublingual, oral, and vaginal administration of misoprostol in the medical treatment of missed abortion during first trimester of pregnancy: A randomized clinical trial study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:72. [PMID: 33088309 PMCID: PMC7554523 DOI: 10.4103/jrms.jrms_393_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/27/2019] [Accepted: 03/27/2020] [Indexed: 01/30/2023]
Abstract
Background: This study was aimed at comparing the efficacy of different routes of misoprostol administration, including sublingual, oral, and vaginal, on the induction of medical abortion in the first trimester of pregnancy. Materials and Methods: This open-label, randomized clinical trial study was performed on 172 individuals in three parallel groups of vaginal, sublingual, and oral administration of misoprostol. The participants were randomized using permuted blocks of six. A dose of 600 μg of misoprostol every 6 h (maximum of 4 doses) was administrated to each group. Higham chart and demographic questionnaires were completed by the investigator. Data were analyzed using Stata software version 12. Results: The mean age of the participants was 29.81 ± 6.7 years, and the mean gestational age was 8.45 ± 2.32 weeks. We found a significant difference regarding the abortion success rate and the time interval between the administration of the drug among three groups (P = 0.036 and < 0.001 in turn). There was no statistically significant difference between the three groups in terms of severity and duration of vaginal bleeding until day 7 after induction (P = 0.091 and 0.143, respectively). Furthermore, we found statistically significant differences in some drugs, which induced side effects namely vomiting and headache, between the three groups (P = 0.032 and 0.028 in turn). Conclusion: The findings suggest that vaginal administration of misoprostol is more successful than the sublingual and oral route for complete abortion; vaginal administration of misoprostol is an appropriate alternative to curettage.
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Affiliation(s)
- Behnaz Souizi
- Department of Obstetrics and Gynecology, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Rahim Akrami
- Department of Community Medicine, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran.,Department of Epidemiology and Biostatistics, School of Public Health, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Fateme Borzoee
- Department of Operating Room, School of Paramedics, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Mohammad Sahebkar
- Department of Social Medicine, School of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
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Izugbara C, Wekesah FM, Sebany M, Echoka E, Amo-Adjei J, Muga W. Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review. Health Care Women Int 2019; 41:732-760. [PMID: 31855511 DOI: 10.1080/07399332.2019.1703991] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.
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Affiliation(s)
| | | | - Meroji Sebany
- International Center for Research on Women, Washington, D.C, USA
| | - Elizabeth Echoka
- Centre for Public Health Research, Kenya Medical Research Institute - KEMRI, Nairobi, Kenya
| | - Joshua Amo-Adjei
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Winstoun Muga
- African Population & Health Research Center, Nairobi, Kenya
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Påfs J, Rulisa S, Klingberg-Allvin M, Binder-Finnema P, Musafili A, Essén B. Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers. Midwifery 2019; 80:102568. [PMID: 31698295 DOI: 10.1016/j.midw.2019.102568] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/10/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Rwanda amended its abortions law in 2012 to allow for induced abortion under certain circumstances. We explore how Rwandan health care providers (HCP) understand the law and implement it in their clinical practice. DESIGN Fifty-two HCPs involved in post-abortion care in Kigali were interviewed by qualitative individual in-depth interviews (n =32) and in focus group discussions (n =5) in year 2013, 2014, and 2016. All data were analyzed using thematic analysis. FINDINGS HCPs express ambiguities on their rights and responsibilities when providing abortion care. A prominent finding was the uncertainties about the legal status of abortion, indicating that HCPs may rely on outdated regulations. A reluctance to be identified as an abortion provider was noticeable due to fear of occupational stigma. The dilemma of liability and litigation was present, and particularly care providers' legal responsibility on whether to report a woman who discloses an illegal abortion. CONCLUSION The lack of professional consensus is creating barriers to the realization of safe abortion care within the legal framework, and challenge patients right for confidentiality. This bring consequences on girl's and women's reproductive health in the setting. IMPLICATIONS FOR PRACTICE To implement the amended abortion law and to provide equitable maternal care, the clinical and ethical guidelines for HCPs need to be revisited.
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Affiliation(s)
- Jessica Påfs
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
| | - Stephen Rulisa
- Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, School of Medicine and Pharmacy, University of Rwanda, P.O.Box 3286, Kigali, Rwanda; Department of Clinical Research, University Teaching Hospital of Kigali, BP 655 Kigali, Rwanda
| | - Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden
| | - Pauline Binder-Finnema
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
| | - Aimable Musafili
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden; Department of Pediatrics and Child Health, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O.Box 217 Butare, Huye, Rwanda
| | - Birgitta Essén
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
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17
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Atuhairwe S, Byamugisha J, Klingberg-Allvin M, Cleeve A, Hanson C, Tumwesigye NM, Kakaire O, Danielsson KG. 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. Trials 2019; 20:376. [PMID: 31227019 PMCID: PMC6588936 DOI: 10.1186/s13063-019-3490-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
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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Affiliation(s)
- Susan Atuhairwe
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
- Mulago National Referral Hospital, Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
| | - Marie Klingberg-Allvin
- Department of Women and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Stockholm, Sweden
- School of Education, Health and Social Sciences, Dalarna University, Falun, Sweden
| | - Amanda Cleeve
- Department of Women and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Stockholm, Sweden
| | - Claudia Hanson
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden
| | - Nazarius Mbona Tumwesigye
- Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
| | - Kristina Gemzell Danielsson
- Department of Women and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Stockholm, Sweden
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Smith PP, Dhillon-Smith RK, O'Toole E, Cooper N, Coomarasamy A, Clark TJ. Outcomes in prevention and management of miscarriage trials: a systematic review. BJOG 2019; 126:176-189. [PMID: 30461160 DOI: 10.1111/1471-0528.15528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes. OBJECTIVE To review systematically, outcomes reported in existing miscarriage trials. SEARCH STRATEGY MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester. DATA COLLECTION AND ANALYSIS Data about the study characteristics, primary, and secondary outcomes were extracted. MAIN RESULTS We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation. CONCLUSIONS Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage. TWEETABLE ABSTRACT There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.
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Affiliation(s)
- P P Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - R K Dhillon-Smith
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - E O'Toole
- Women's Voices Involvement Panel, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nam Cooper
- Barts and the London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - T J Clark
- Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Tommy's Centre for Miscarriage Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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19
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Odland ML, Membe-Gadama G, Kafulafula U, Odland JØ, Darj E. "Confidence comes with frequent practice": health professionals' perceptions of using manual vacuum aspiration after a training program. Reprod Health 2019; 16:20. [PMID: 30782201 PMCID: PMC6381708 DOI: 10.1186/s12978-019-0683-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 02/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended. METHODS The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced. RESULTS Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work. CONCLUSION Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.
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Affiliation(s)
- Maria Lisa Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.
| | | | | | - Jon Øyvind Odland
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,College of Medicine, University of Malawi, Blantyre, Malawi.,University of Pretoria, Pretoria, South Africa
| | - Elisabeth Darj
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim, Norway.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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20
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Endler M, Beets L, Gemzell Danielsson K, Gomperts R. Safety and acceptability of medical abortion through telemedicine after 9 weeks of gestation: a population-based cohort study. BJOG 2018; 126:609-618. [DOI: 10.1111/1471-0528.15553] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M Endler
- Division of Obstetrics and Gynecology; Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - L Beets
- Department of Health Sciences; Vrije Universiteit Amsterdam; Amsterdam the Netherlands
| | - K Gemzell Danielsson
- Division of Obstetrics and Gynecology; Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - R Gomperts
- Women on Web International Foundation; Amsterdam the Netherlands
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21
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Fullerton J, Butler MM, Aman C, Reid T, Dowler M. Abortion-related care and the role of the midwife: a global perspective. Int J Womens Health 2018; 10:751-762. [PMID: 30538585 PMCID: PMC6260173 DOI: 10.2147/ijwh.s178601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016-2017 update study about these three items are presented. Methods A modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented. Results A total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development. Conclusion The role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized.
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Affiliation(s)
- Judith Fullerton
- Retired, School of Medicine, University of California, San Diego, CA, USA,
| | - Michelle M Butler
- Faculty of Science and Health, Dublin City University, Dublin 9, Ireland
| | - Cheryl Aman
- Midwifery Program, University of British Columbia, Vancouver, BC, Canada
| | - Tobi Reid
- Midwifery Program, University of British Columbia, Vancouver, BC, Canada
| | - Melanie Dowler
- Midwifery Program, University of British Columbia, Vancouver, BC, Canada
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22
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Cresswell JA, Owolabi OO, Chelwa N, Dennis ML, Gabrysch S, Vwalika B, Mbizvo M, Filippi V, Campbell OMR. Does supportive legislation guarantee access to pregnancy termination and postabortion care services? Findings from a facility census in Central Province, Zambia. BMJ Glob Health 2018; 3:e000897. [PMID: 30233831 PMCID: PMC6135439 DOI: 10.1136/bmjgh-2018-000897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Zambia is one of the few countries in Africa to permit termination of pregnancy (TOP) on a wide range of grounds. However, substantial barriers remain to TOP and postabortion care (PAC). Methods We conducted a census of 153 facilities between March and May 2016. We defined facilities according to whether they met basic and/or comprehensive signal functions criteria for TOP and PAC. We linked our facility data to census data to estimate geographic accessibility under different policy scenarios. Results Overall, 16% of facilities reported they had performed a TOP and 39% performed a PAC in the last year. Facilities were twice as likely to use medical methods for TOP compared with surgical methods, and four times more likely for PAC. Considerably more facilities had performed TOP or PAC than met the basic or comprehensive signal functions criteria, indicating services were being performed in facilities below essential quality standards. Under current Zambian law for non-emergency scenarios, 21% of women in Central Province lived within 15 km of a facility with basic capability to provide TOP; if midlevel providers were trained to provide TOP, this would increase to 36%. Conclusion A supportive legislative framework is essential, but not in itself sufficient, for adequate access to services. Training midlevel providers, in line with WHO guidance, and ensuring equipment is available in primary care can increase accessibility of TOP and PAC. While both medical and surgical methods need to be available, medical abortion is a safe and effective method that can be provided in low-resource settings.
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Affiliation(s)
- Jenny A Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Onikepe O Owolabi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mardieh L Dennis
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sabine Gabrysch
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | | | | | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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23
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Klingberg-Allvin M, Atuhairwe S, Cleeve A, Byamugisha JK, Larsson EC, Makenzius M, Oguttu M, Gemzell-Danielsson K. Co-creation to scale up provision of simplified high-quality comprehensive abortion care in East Central and Southern Africa. Glob Health Action 2018; 11:1490106. [PMID: 29972099 PMCID: PMC6032022 DOI: 10.1080/16549716.2018.1490106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Universal access to comprehensive abortion care (CAC) is a reproductive right and is essential to reduce preventable maternal mortality and morbidity. In East Africa, abortion rates are consistently high, and the vast majority of all abortions are unsafe, significantly contributing to unnecessary mortality and morbidity. The current debate article reflects and summarises key action points required to continue to speed the implementation of and expand access to CAC in the East, Central, and Southern African (ECSA) health community. To ensure universal access to quality CAC, a regional platform could facilitate the sharing of best practices and successful examples from the region, which would help to visualise opportunities. Such a platform could also identify innovative ways to secure women’s access to quality care within legally restrictive environments and would provide information and capacity building through the sharing of recent scientific evidence, guidelines, and training programmes aimed at increasing women’s access to CAC at the lowest effective level in the healthcare system. This type of infrastructure for exchanging information and developing co-creation could be crucial to advancing the Sustainable Development Goals 2030 agenda.
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Affiliation(s)
- M Klingberg-Allvin
- a Department of Women's and Children's Health , Karolinska Institutet , Stockholm , Sweden.,b School of Education, Health and Social Studies , Dalarna University , Falun , Sweden
| | - S Atuhairwe
- c Makerere University College of Health Sciences , Kampala , Uganda
| | - A Cleeve
- a Department of Women's and Children's Health , Karolinska Institutet , Stockholm , Sweden
| | - J K Byamugisha
- c Makerere University College of Health Sciences , Kampala , Uganda
| | - E C Larsson
- a Department of Women's and Children's Health , Karolinska Institutet , Stockholm , Sweden
| | - M Makenzius
- d Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - M Oguttu
- e Kenya Medical and Education Trust (KMET) , Kisumu , Kenya
| | - K Gemzell-Danielsson
- a Department of Women's and Children's Health , Karolinska Institutet , Stockholm , Sweden
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24
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Cleeve A, Oguttu M, Ganatra B, Atuhairwe S, Larsson EC, Makenzius M, Klingberg-Allvin M, Paul M, Kakaire O, Faxelid E, Byamugisha J, Gemzell-Danielsson K. Time to act-comprehensive abortion care in east Africa. LANCET GLOBAL HEALTH 2018; 4:e601-2. [PMID: 27539801 DOI: 10.1016/s2214-109x(16)30136-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden.
| | | | - Bela Ganatra
- WHO, Department of Reproductive Health and Research, Geneva, Switzerland
| | - Susan Atuhairwe
- Department of Obstetrics and Gynecology, Mulago Hospital, Kampala, Uganda; Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elin C Larsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska University Hospital, Uppsala, Sweden
| | - Marlene Makenzius
- Department of Public Health Sciences/Global Health, Karolinska Institutet, Stockholm, Sweden; School of Nursing, College of Health Sciences, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Marie Klingberg-Allvin
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Mandira Paul
- Department of Women's and Children's Health/IMCH, Uppsala University, Akademiska University Hospital, Uppsala, Sweden
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Mulago Hospital, Kampala, Uganda; Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elisabeth Faxelid
- Department of Public Health Sciences/Global Health, Karolinska Institutet, Stockholm, Sweden
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Mulago Hospital, Kampala, Uganda; Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
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25
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Sjöström S, Dragoman M, Fønhus MS, Ganatra B, Gemzell‐Danielsson K. Effectiveness, safety, and acceptability of first-trimester medical termination of pregnancy performed by non-doctor providers: a systematic review. BJOG 2017; 124:1928-1940. [PMID: 28445596 PMCID: PMC5724486 DOI: 10.1111/1471-0528.14712] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous systematic reviews have concluded that medical termination of pregnancy (TOP) performed by non-doctor providers may be as effective and safe as when provided by doctors. Medical treatment of incomplete miscarriage by non-doctor providers and the treated women's acceptance of non-doctor providers of TOP has not previously been reviewed. OBJECTIVES To review the effectiveness, safety, and acceptability of first-trimester medical TOP, including medical treatment for incomplete miscarriage, by trained non-doctor providers. SEARCH STRATEGY AND SELECTION CRITERIA A search strategy using appropriate medical subject headings was developed. Electronic databases (PubMed, Popline, Cochrane, CINAHL, Embase, and ClinicalTrials.gov) were searched from inception through April 2016. Randomised controlled trials and comparative observational studies were included. DATA COLLECTION AND ANALYSIS Meta-analyses were performed for included randomised controlled trials regarding the outcomes of effectiveness and acceptability to women. Certainty of evidence was established using the GRADE approach assessing study limitations, consistency of effect, imprecision, indirectness and publication bias. MAIN RESULTS Six papers were included. Medical TOP and medical treatment of incomplete miscarriage is probably equally effective when performed by non-doctor providers as when performed by doctors (RR 1.00; 95% CI 0.99-1.01). Women's acceptance, reported as overall satisfaction with the allocated provider, is probably equally high between groups (RR 1.00; 95% CI 1.00-1.01). CONCLUSION Medical TOP and medical treatment of incomplete miscarriage provided by trained non-doctor providers is probably equally as effective and acceptable to women as when provided by doctors. TWEETABLE ABSTRACT Medical termination of pregnancy performed by doctors and non-doctors can be equally effective and acceptable.
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Affiliation(s)
- S Sjöström
- Department of Women's and Children's HealthKarolinska InstitutetKarolinska University HospitalStockholmSweden
| | - M Dragoman
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)Department of Reproductive HealthWorld Health OrganizationGenevaSwitzerland
| | - MS Fønhus
- Norwegian Institute of Public HealthOsloNorway
| | - B Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of ResearchDevelopment and Research Training in Human Reproduction (HRP)Department of Reproductive HealthWorld Health OrganizationGenevaSwitzerland
| | - K Gemzell‐Danielsson
- Department of Women's and Children's HealthKarolinska InstitutetKarolinska University HospitalStockholmSweden
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26
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Tebbets C, Santana D, Ros Silvestre J, Redwine D. Building Bridges: A Case for Community Health Worker Provision of Misoprostol-Only Abortion in the First Trimester. J Womens Health (Larchmt) 2017; 27:311-316. [PMID: 29040004 DOI: 10.1089/jwh.2016.6144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The consequences of unsafe abortion are devastating to women, their families, and their communities. Medication abortion presents an important alternative to harmful self-induction practices and surgical intervention under questionable circumstances. In settings where mifepristone is unavailable, the use of misoprostol alone is a safe and effective option for terminating an unwanted pregnancy. Studies have demonstrated the safety and efficacy of administration of misoprostol by community health workers (CHW) for indications such as postpartum hemorrhage and treatment of incomplete abortion. OBJECTIVES The current study assesses the safety and efficacy of CHW managing misoprostol-only abortion in the first trimester. METHODS A retrospective review of clinical files of women who received abortion services in three countries in Latin America between April 2009 and December 2015 included analysis of 173 cases. RESULTS In 94% of cases, the pregnancy was terminated without any further intervention. In the remaining cases, clients were referred for manual vacuum aspiration. In four cases, a complication was reported by the provider. In one, the complication was promptly resolved through referral to a higher level of care; in the remaining three, the complication was resolved directly by the provider. In 98% of cases, women reported being satisfied with the treatment they received. CONCLUSION This study demonstrates that CHW are able to provide misoprostol-only abortion services to women effectively and safely. The benefits of this model of care also extend beyond the abortion service: CHW are able to offer women a comprehensive range of quality health services, including contraceptive services, increasing access to vital healthcare in areas with few other options.
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Affiliation(s)
- Claire Tebbets
- Planned Parenthood Global, Planned Parenthood Federation of America , Miami, Florida
| | - Diana Santana
- Planned Parenthood Global, Planned Parenthood Federation of America , Miami, Florida
| | - José Ros Silvestre
- Planned Parenthood Global, Planned Parenthood Federation of America , Miami, Florida
| | - Dee Redwine
- Planned Parenthood Global, Planned Parenthood Federation of America , Miami, Florida
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27
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Makenzius M, Oguttu M, Klingberg-Allvin M, Gemzell-Danielsson K, Odero TMA, Faxelid E. 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. BMJ Open 2017; 7:e016157. [PMID: 29018067 PMCID: PMC5652492 DOI: 10.1136/bmjopen-2017-016157] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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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Affiliation(s)
- Marlene Makenzius
- Department of Public Health Sciences Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Monica Oguttu
- Kisumu Medical and Education Trust (KMET), Reproductive Health, Kisumu, Kenya
| | - Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
- Department of Women ´s and Children ´s Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Division of Obstetrics and Gynaecology, Karolinska University Hospital, Stockholm, Sweden
- Departement of Women ´s and Children ´s Health, Karolinska Institutet, Stockholm, Sweden
| | - Theresa M A Odero
- College of Health Sciences, School of Nursing Sciences, University of Nairobi, Nairobi, Kenya
| | - Elisabeth Faxelid
- Department of Public Health Sciences Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227. [PMID: 27873322 PMCID: PMC6464275 DOI: 10.1002/14651858.cd011227.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Affiliation(s)
- Greg Weeks
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
- Barwon HealthPharmacy DepartmentGeelongVictoriaAustralia
| | - Johnson George
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
| | - Katie Maclure
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
| | - Derek Stewart
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
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Yigzaw T, Carr C, Stekelenburg J, van Roosmalen J, Gibson H, Gelagay M, Admassu A. Using task analysis to generate evidence for strengthening midwifery education, practice, and regulation in Ethiopia. Int J Womens Health 2016; 8:181-90. [PMID: 27313478 PMCID: PMC4890695 DOI: 10.2147/ijwh.s105046] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Realizing aspirations for meeting the global reproductive, maternal, newborn, and child health goals depends not only on increasing the numbers but also on improving the capability of midwifery workforce. We conducted a task analysis study to identify the needs for strengthening the midwifery workforce in Ethiopia. METHODS We conducted a cross-sectional study of recently qualified midwives in Ethiopia. Purposively selected participants from representative geographic and practice settings completed a self-administered questionnaire, making judgments about the frequency of performance, criticality, competence, and location of training for a list of validated midwifery tasks. Using Statistical Package for the Social Sciences, Version 20, we computed the percentages and averages to describe participant and practice characteristics. We identified priority preservice education gaps by considering the tasks least frequently learned in preservice, most frequently mentioned for not being trained, and had the highest not capable response. Identification of top priorities for in-service training considered tasks with highest "not capable" and "never" done responses. We determined the licensing exam blueprint by weighing the composite mean scores for frequency and criticality variables and expert rating across practice categories. RESULTS One hundred and thirty-eight midwives participated in the study. The majority of respondents recognized the importance of midwifery tasks (89%), felt they were capable (91.8%), reported doing them frequently (63.9%), and learned them during preservice education (56.3%). We identified competence gaps in tasks related to obstetric complications, gynecology, public health, professional duties, and prevention of mother to child transmission of HIV. Moreover, our study helped to determine composition of the licensing exam for university graduates. CONCLUSION The task analysis indicates that midwives provide critical reproductive, maternal, newborn, and child health care services and supports continuing investment in this cadre. However, there were substantial competence gaps that limit their ability to accelerate progress toward health development goals. Moreover, basing the licensure exam on task analysis helped to ground it in national practice priorities.
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Affiliation(s)
| | | | - Jelle Stekelenburg
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Jos van Roosmalen
- Faculty of Earth and Life Sciences, Vrije Universiteit, Amsterdam, the Netherlands
| | | | | | - Azeb Admassu
- Federal Ministry of Health, Addis Ababa, Ethiopia
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Cleeve A, Byamugisha J, Gemzell-Danielsson K, Mbona Tumwesigye N, Atuhairwe S, Faxelid E, Klingberg-Allvin M. 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. PLoS One 2016; 11:e0149172. [PMID: 26872219 PMCID: PMC4752492 DOI: 10.1371/journal.pone.0149172] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/26/2016] [Indexed: 11/28/2022] Open
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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Affiliation(s)
- Amanda Cleeve
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- WHO Center for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Nazarius Mbona Tumwesigye
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Susan Atuhairwe
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Elisabeth Faxelid
- Department of Public Health Sciences, Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Marie Klingberg-Allvin
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
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Badawy AM, Elnashar AM. Treatment with misoprostol by midwives is safe and effective. Lancet 2015; 385:2335-7. [PMID: 25817471 DOI: 10.1016/s0140-6736(14)62287-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ahmed M Badawy
- Department of Obstetrics and Gynecology, Mansura University, Mansoura 35111, Egypt.
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