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Johnston HB, Footman K, Ali MM, Aly EA, Asmani C, Asrat SG, Atweam DK, Awais S, Ayiasi RM, Boamah MO, Chooye O, Doe R, Droti B, Elamin H, Fofie C, Gholbzouri K, Hadush A, Hemachandra N, Hien Y, Kasolo FC, Kipruto H, Lainez YB, Natseri N, Onyiah PA, Orach CG, Ouangare A, Ouedraogo L, Sentumbwe-Mugisa O, Sheffel A, Siyam A, Ssendyona M, Thom E, Tingueri RK, Traoré S, Uzma Q, Venter W, Ganatra B. Measuring availability of and facility readiness to deliver comprehensive abortion care: experiences and lessons learnt from integrating abortion into WHO's health facility assessments. BMJ Glob Health 2024; 8:e015097. [PMID: 39122445 PMCID: PMC11344866 DOI: 10.1136/bmjgh-2024-015097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Routine assessment of health facility capacity to provide abortion and post-abortion care can inform policy and programmes to expand access and improve quality. Since 2018, abortion and/or post-abortion care have been integrated into two WHO health facility assessment tools: the Service Availability and Readiness Assessment and the Harmonised Health Facility Assessment. We discuss lessons learnt through experiences integrating abortion into these standardised tools. Our experiences highlight the feasibility of including abortion in health facility assessments across a range of legal contexts. Factors facilitating the integration of abortion include cross-country collaboration and experience sharing, timely inputs into tool adaptations, clear leadership, close relationships among key stakeholders as in assessment coordination groups, use of locally appropriate terminology to refer to abortion and reference to national policies and guidelines. To facilitate high-quality data collection, we identify considerations around question sequencing in tool design, appropriate terminology and the need to balance the normalisation of abortion with adequate sensitisation and education of data collectors. To facilitate appropriate and consistent analysis, future work must ensure adequate disaggregation of recommended and non-recommended abortion methods, alignment with national guidelines and development of a standardised approach for measuring abortion service readiness. Measurement of abortion service availability and readiness should be a routine practice and a standardised component of health facility assessment tools. Evidence generated by health facility assessments that include abortion monitoring can guide efforts to expand access to timely and effective care and help normalise abortion as a core component of sexual and reproductive healthcare.
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Affiliation(s)
- Heidi Bart Johnston
- 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
| | - Katy Footman
- 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
| | - Mohamed Mahmoud Ali
- 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
| | - Eman Abdelkreem Aly
- World Health Organisation Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Chilanga Asmani
- formerly, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | | | | | - Sayema Awais
- Pakistan Ministry of National Health Services Regulations and Coordination, Islamabad, Pakistan
| | | | | | | | | | - Benson Droti
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Hayfa Elamin
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Chris Fofie
- Family Health Division, Ghana Health Service, Accra, Ghana
| | - Karima Gholbzouri
- World Health Organisation Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | | | | | - Yelmali Hien
- Burkina Faso, World Health Organization, Ouagadougou, Burkina Faso
| | | | - Hillary Kipruto
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | | | | | | | | | - Assane Ouangare
- Directorate of Statistics, Ministry of Health Burkina Faso, Ouagadougou, Burkina Faso
| | - Leopold Ouedraogo
- World Health Organization Regional Office for Africa, Brazzaville, Congo
| | | | - Ashley Sheffel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amani Siyam
- World Health Organization Regional Office for South-East Asia, New Delhi, New Delhi, India
| | - Martin Ssendyona
- Department for Standards Accreditation and Patient Protection, Republic of Uganda Ministry of Health, Kampala, Uganda
| | - Ellen Thom
- Pakistan, World Health Organization, Islamabad, Pakistan
| | | | - Soumaïla Traoré
- Directorate of Statistics, Ministry of Health Burkina Faso, Ouagadougou, Burkina Faso
| | - Qudsia Uzma
- Pakistan, World Health Organization, Islamabad, Pakistan
| | - Wendy Venter
- Data and Analytics, World Health Organization, Geneva, Switzerland
| | - Bela Ganatra
- 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
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Abiyo J, Nabirye RC, Nambozo B, Mukunya D, Nantale R, Oguttu F, Wani S, Musaba MW, Tumuhamye J, Epuitai J. "I have come to remove it because of heavy bleeding": a mixed-methods study on early contraceptive implant removal and the underlying factors in eastern Uganda. Contracept Reprod Med 2024; 9:17. [PMID: 38627845 PMCID: PMC11020533 DOI: 10.1186/s40834-024-00279-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Early contraceptive implant removal without intentions to conceive predisposes women to unintended pregnancies.. Some of the unintended pregnancies end in unsafe abortions which further increases the risk of maternal mortality and morbidity. Therefore, we assessed the proportion of women who had early contraceptive implant removal. We also explored the reasons for early contraceptive implant removalamong women at Mbale Regional Referral Hospital in eastern Uganda. METHODS We conducted a sequential explanatory mixed methods study at Mbale Regional Referral Hospital between November 2022 to December 2022. For quantitative data, we performed a secondary analysis on data extracted from the integrated family planning registers. We used systematic random sampling to select 600 clients' serial numbers from the registers. The outcome variable was early contraceptive implant removal defined as removal of the implant by the woman before 18 months from the time of insertion. For qualitative data, we conducted 11 in-depth interviews among women who had come for contraceptive implant removal at the family planning clinic. We also conducted two key informant interviews with midwives working at the family planning unit. Quantitative data were analysed using Stata version 14.0 (Stata Corp LLC, College Station, Texas, USA) while qualitative data were analysed by thematic content analysis. RESULTS In this study, 15% (91/600) of the women discontinued contraceptive implants within 12 months, 29% (175/600) within 18 months, 38% (230/600) within 24 months and 40% (240/600) within 36 months of insertion. Among the women who discontinued contraceptive implant use, only 6.7% (40/600) switched to another family planning method. Out of the 175 women who removed contraceptive implants early, side effects 61.1% (107/175) desire to conceive 53.1% ( 93/175),, and gender-based violence 8.6% (15/175) were the major reasons for removal. From the qualitative interviews, the major reasons for early contraceptive implant removal were side effects such as heavy menstrualbleeding. CONCLUSION A third of women discontinued contraceptive implant use within 18 months. Addressing concerns regarding side effects and male partner disapproval of modern contraceptives may improve continued use of implants.
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Affiliation(s)
- Janet Abiyo
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Rose Chalo Nabirye
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Brendah Nambozo
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda.
| | - David Mukunya
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Ritah Nantale
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Faith Oguttu
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Solomon Wani
- Department of Community and Public Health, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
- Busitema University Centre of Excellency for Maternal Reproductive and Child Health, Mbale, Uganda
| | - Josephine Tumuhamye
- Makerere University Hospital, Makerere University Kampala, Kampala, P.O.BOX 7062, Uganda
| | - Joshua Epuitai
- Department of Nursing, Faculty of Health Sciences, Busitema University, Mbale, P.0 Box 1460, Uganda
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Ferro HP, Williams K, Holbrook DS, O'Conor KJ. Disproportionate impact of abortion restriction: Implications for emergency department clinicians. Am J Emerg Med 2023; 69:160-166. [PMID: 37121065 DOI: 10.1016/j.ajem.2023.04.022] [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: 12/20/2022] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023] Open
Abstract
Individuals experiencing intimate partner violence (IPV) and/or human trafficking (HT) are at increased risk of severe health consequences as a result of legislation criminalizing and/or restricting abortion, which is expected to increase as a result of the Supreme Court decision Dobbs v. Jackson. These risks are further stratified by race, socioeconomics, and other marginalizing demographic attributes. IPV and HT introduce barriers to maintaining physical and mental health, due to control of access to transportation and funds by the abuser, fear of retribution for seeking healthcare, and other barriers. Individuals experiencing IPV or HT often lack reproductive autonomy, as a result of facing reproductive coercion at the hands of their abusers. Following the Dobbs decision, these vulnerable patient populations will face further limitations on their reproductive autonomy and increased obstacles to obtaining an abortion if they medically need or desire one. This will likely result in more patients presenting to the emergency department due to complications from unsafe or unsupervised self-managed abortions, as well as patients being reluctant to report having obtained an unlawful abortion due to fear of legal consequences. This is particularly relevant to individuals experiencing IPV and HT, as they may be more likely to use these methods for obtaining an abortion due to numerous barriers. Emergency medicine clinicians are vital in providing care to these patients, as they frequently present to emergency departments. A multi-pronged approach to better support these patients is essential, involving an increased index of suspicion for IPV, HT or the complications of unsupervised abortion, improved organizational structures, specialized training for staff, improved screening methods, reflection on implicit bias, and recommendations for mindful documentation and legal considerations.
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Affiliation(s)
- Haleigh P Ferro
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21287, United States.
| | - Kelly Williams
- Johns Hopkins Medicine, 1800 Orleans St, Baltimore, MD 21287, United States.
| | - Debra S Holbrook
- Mercy Medical Center, 345 St. Paul Pl, Baltimore, MD 21202, United States.
| | - Katie J O'Conor
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21287, United States.
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Stillman M, Kibira SPS, Shiferaw S, Makumbi F, Seme A, Sully EA, Ha L, Giorgio M. Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda. BMC Health Serv Res 2023; 23:104. [PMID: 36726121 PMCID: PMC9890752 DOI: 10.1186/s12913-022-09017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 12/28/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect. METHODS We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period. RESULTS In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%. CONCLUSIONS The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.
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Affiliation(s)
- Melissa Stillman
- Guttmacher Institute, 125 Maiden Lane, New York, NY, 10038, USA.
| | - Simon P S Kibira
- School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Rd, Kampala, Uganda
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Rd, Kampala, Uganda
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Lilian Ha
- Guttmacher Institute, 125 Maiden Lane, New York, NY, 10038, USA
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Kagaha A, Manderson L. Reproductive materialism and justice for women with abortion care needs in Uganda. Glob Public Health 2022; 17:3476-3492. [PMID: 36223332 DOI: 10.1080/17441692.2022.2129722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution. While language discourses conceal and normalise reproductive health injustices, discursive practices of care and priority setting enable reproductive controls to be navigated in ways that amplify these injustices and create new ones. In interventions, precarious conditions that impact women's reproductive health and living circumstances are often overlooked or concealed. We illustrate the convergence of biopower and necropolitical strategies to illuminate these conditions. Using the concept of reproductive materialism, we show how neoliberalism cultivates particular conditions of everyday life, in which populations are positioned as instruments for pecuniary motives, and normative controls are used to further financial gain.
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Affiliation(s)
- Alexander Kagaha
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Social Sciences, Monash University, Melbourne, Victoria, Australia
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Atuhairwe S, Hanson C, Atuyambe L, Byamugisha J, Tumwesigye NM, Ssenyonga R, Gemzell-Danielsson K. Evaluating women’s acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians: a mixed methods study. BMC Womens Health 2022; 22:434. [PMID: 36335344 PMCID: PMC9637300 DOI: 10.1186/s12905-022-02027-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
Abstract
Background Studies evaluating task sharing in postabortion care have mainly focused on women in first trimester and many lack a qualitative component. We aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients’ lived treatment experiences in Uganda. Methods Our mixed methods study combined 1140 structured interview data from a randomized controlled equivalence trial and in-depth interviews (n = 28) among women managed with misoprostol for second trimester incomplete abortion at 14 public health facilities in Uganda. Acceptability, our main outcome, was measured at the 14-day follow-up visit using a structured questionnaire as a composite variable of: 1) treatment experience (as expected/ better than expected/ worse than expected), and 2) satisfaction - if patient would recommend the treatment to a friend or choose the method again. We used generalized mixed effects models to obtain the risk difference in acceptable post abortion care between midwife and physician groups. We used inductive content analysis for qualitative data. Results From 14th August 2018 to 16th November 2021, we assessed 7190 women for eligibility and randomized 1191 (593 to midwife and 598 to physician). We successfully followed up 1140 women and 1071 (94%) found the treatment acceptable. The adjusted risk difference was 1.2% (95% CI, − 1.2 to 3.6%) between the two groups, and within our predefined equivalence range of − 5 to + 5%. Treatment success and feeling calm and safe after treatment enhanced acceptability while experience of side effects and worrying bleeding patterns reduced satisfaction. Conclusions Misoprostol treatment of uncomplicated second trimester incomplete abortion was equally and highly acceptable to women when care was provided by midwives compared with physicians. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient’s access to postabortion care services. Trial registration ClinicalTrials.gov NCT03622073. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-02027-y. Approximately 9.6% of abortion-related deaths occur in Sub-Saharan Africa. These deaths can be prevented if unintended pregnancies are avoided, women can access safe abortions within the expectations of the country’s laws, and post abortion care (PAC) services are provided equitably. Previous research shows that women with abortion complications in the first trimester of pregnancy can be treated with misoprostol by either midwives or physicians. This sharing of tasks between the midwives and physicians is safe, effective, and acceptable. However, there is a gap in evidence on task sharing in the second trimester. To check practicability of task sharing in second trimester, we aimed to evaluate patient acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians and also gained a deeper understanding of the patients’ lived treatment experiences. Our study therefore combined quantitative and qualitative approaches. Women’s acceptability of misoprostol treatment for incomplete second trimester abortion was found to be equally acceptable when provided by midwives compared with physicians. Treatment success, feeling calm and safe after treatment increased acceptability, while experience of side effects and worrying bleeding patterns reduced satisfaction. Counselling of women may address some of these problems since it provides reassurance and reduces anxiety. In settings that lack adequate staffing levels of physicians or where midwives are available to provide misoprostol, task sharing second trimester medical PAC with midwives increases patient’s access to PAC services.
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Affiliation(s)
- Susan Atuhairwe
- grid.11194.3c0000 0004 0620 0548Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda ,Department of Reproductive Medicine and Infertility, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | - Claudia Hanson
- grid.465198.7Department of Public Health Sciences, Karolinska Institutet, Solna, Sweden ,grid.8991.90000 0004 0425 469XDepartment of disease control, London School of Hygiene and Tropical Medicine, London, UK
| | - Lynn Atuyambe
- grid.11194.3c0000 0004 0620 0548Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Josaphat Byamugisha
- grid.11194.3c0000 0004 0620 0548Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | - Nazarius Mbona Tumwesigye
- grid.11194.3c0000 0004 0620 0548Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Ronald Ssenyonga
- grid.11194.3c0000 0004 0620 0548Department of Epidemiology & Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Kristina Gemzell-Danielsson
- grid.4714.60000 0004 1937 0626Department of Women and Children’s Health, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705WHO Collaborating Centre, Karolinska University Hospital, 17176 Stockholm, Sweden
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Mulongo S, Kaura DM, Mash B. Determinants of Obstetric Near Miss in a Tertiary Hospital in Kenya: A Retrospective Study. INTERNATIONAL JOURNAL OF CHILDBIRTH 2022. [DOI: 10.1891/ijc-2021-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUNDKenya has a high burden of facility maternal deaths but there is scarce utilization of the near miss approach to understand facility related determinants of maternal mortality. The aim of this study was to investigate determinants of near miss in a major refferal hospital in Kenya using the World Health Organization near miss approach.METHODSA retrospective study design was used in a referral hospital in Kenya. Prevalence, direct and indirect causes of near miss were determined. Binomial logistic regression was used to determine associations between maternal characteristics and maternal near miss.RESULTSMaternal near miss ratio was 8.7 per 1000 live births. The most prevalent direct factors were: Severe post-partum hemorrhage (35%), eclampsia (18.9%) severe pre-eclampsia (17.4%), blood transfusion (79%), and hepatic dysfunction (3.7%). Anemia, previous ceaserean section and prolonged/obstructed labor were the most important contributory factors. The prevalence of organ dysfunction at admission was 39%. Only 74% of eclampsia cases had received magnesium sulphate on referral. Higher gestation at delivery (AOR = 0.640, 95% C.I =0.477–0.858) and those who received antenatal care from a level two or three facility (AOR = 0.190, 95% CI = 0.042–0.856) were less likely to experience a near miss.CONCLUSIONObstetric hemorrhage and pregnancy induced hypertension were the most important direct determinants of near miss, while anemia was the most important indirect determinant. Organ dysfunction on admission to the tertiary referral facility was high, suggesting delays in interventions at lower level facilities. Interventions addressing obstetric hemorrhage, pregnancy induced hypertension and pre-natal anemia may reduce the burden of near miss and mortality.
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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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Áinle FN, Donnelly J, Eogan M. Response to: "Are women equal? Considering impact of therapeutic abortion bans on science". Res Pract Thromb Haemost 2022; 6:e12754. [PMID: 35833171 PMCID: PMC9265638 DOI: 10.1002/rth2.12754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Fionnuala Ní Áinle
- School of Medicine University College Dublin (UCD) Dublin Ireland.,Department of Haematology Rotunda Hospital Dublin Ireland.,Department of Haematology Mater Misericordiae University Hospital Dublin Ireland
| | - Jennifer Donnelly
- Department of Obstetrics Rotunda Hospital Dublin Ireland.,Department of Obstetrics and Gynaecology Royal College of Surgeons in Ireland Dublin Ireland
| | - Maeve Eogan
- Department of Obstetrics Rotunda Hospital Dublin Ireland.,Department of Obstetrics and Gynaecology Royal College of Surgeons in Ireland Dublin Ireland
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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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Namagembe I, Nakimuli A, Byamugisha J, Moffett A, Aiken A, Aiken C. Preventing death following unsafe abortion: a case series from urban Uganda. AJOG GLOBAL REPORTS 2022; 2:100039. [PMID: 35252906 PMCID: PMC8883508 DOI: 10.1016/j.xagr.2021.100039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Maternal deaths from unsafe abortion continue to occur globally, with particularly high rates in Sub-Saharan Africa where most abortions are classified as unsafe. Maternal death reviews are an effective part of cohesive strategies to prevent future deaths while abortion remains illegal. OBJECTIVE This study aimed to conduct maternal death reviews for all deaths occurring following unsafe abortion during the study period, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following unsafe abortions. STUDY DESIGN Full case reviews of all maternal deaths (350 cases from Jan 2016 to Dec 2018) at the study center (a national referral hospital in urban Uganda) were conducted by specially trained multidisciplinary panels of obstetricians and midwives. We extracted the reviews of women who died following unsafe abortions (13 [2.6%]) for further analysis. RESULTS Most maternal deaths owing to unsafe abortion were found to be preventable. The key recommendations that emerged from the reviews were (1) that clinicians should maintain a high index of suspicion for delayed presentation and rapid decompensation in cases where unsafe abortion has occurred, (2) that a low threshold for early intravenous antibiotic therapy should be applied, and (3) that any admission with complications following an unsafe abortion merits review by an experienced clinician as soon as possible. CONCLUSION Postabortion care is part of essential emergency medical care and should be provided with high standards, especially in areas where there is limited or no legal access to abortion care. Implementing the recommended learning points is likely to be feasible even in low-resource obstetrical settings and, given the high rates of preventability found in maternal deaths owing to unsafe abortion, is likely to be effective.
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Compaoré R, Mehrtash H, Calvert C, Qureshi Z, Bello FA, Baguiya A, Msusa AT, Idi N, Govule P, Tunçalp Ӧ, Kouanda S. Health facilities’ capability to provide comprehensive postabortion care in Sub‐Saharan Africa: Evidence from a cross‐sectional survey across 210 high‐volume facilities. Int J Gynaecol Obstet 2022; 156 Suppl 1:7-19. [DOI: 10.1002/ijgo.14056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Rachidatou Compaoré
- Research Institute of Health Sciences Ouagadougou Burkina Faso
- Doctoral School Saint Thomas d’Aquin University Ouagadougou Burkina Faso
| | - Hedieh Mehrtash
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Clara Calvert
- Centre for Global Health Usher Institute University of Edinburgh Edinburgh UK
| | - Zahida Qureshi
- Department of Obstetrics and Gynecology Faculty of Health Sciences University of Nairobi Nairobi Kenya
| | | | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya‐HDSS) Research Institute of Health Sciences Ouagadougou Burkina Faso
| | - Ausbert Thoko Msusa
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi Blantyre Malawi
| | - Nafiou Idi
- Université Abdou Moumouni de Niamey Niamey Niger
| | - Philip Govule
- Department of Epidemiology and Disease Control School of Public Health University of Ghana Accra Ghana
| | - Ӧzge Tunçalp
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Seni Kouanda
- Research Institute of Health Sciences Ouagadougou Burkina Faso
- Doctoral School Saint Thomas d’Aquin University Ouagadougou Burkina Faso
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Baguiya A, Mehrtash H, Bonet M, Adu‐Bonsaffoh K, Compaoré R, Bello FA, Govule P, Msusa AT, Kim CR, Kouanda S. Abortion‐related infections across 11 countries in Sub‐Saharan Africa: Prevalence, severity, and management. Int J Gynaecol Obstet 2022; 156 Suppl 1:36-43. [DOI: 10.1002/ijgo.14032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya‐HDSS) Research Institute of Health Sciences Ouagadougou Burkina Faso
- Doctoral School Saint Thomas d'Aquin University Ouagadougou Burkina Faso
| | - Hedieh Mehrtash
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Mercedes Bonet
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
- Department of Obstetrics and Gynecology University of Ghana Medical School Accra Ghana
| | - Kwame Adu‐Bonsaffoh
- Biomedical and Public Health Department Research Institute of Health Sciences Ouagadougou Burkina Faso
| | - Rachidatou Compaoré
- Biomedical and Public Health Department Research Institute of Health Sciences Ouagadougou Burkina Faso
| | | | - Philip Govule
- Department of Epidemiology and Disease Control School of Public Health University of Ghana Accra Ghana
| | - Ausbert Thoko Msusa
- Department of Obstetrics and Gynecology College of Medicine University of Malawi Blantyre Malawi
| | - Caron R. Kim
- Department of Sexual and Reproductive Health and Research UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) World Health Organization Geneva Switzerland
| | - Séni Kouanda
- Biomedical and Public Health Department Research Institute of Health Sciences Ouagadougou Burkina Faso
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Wolomby-Molondo JJ, Calvert C, Seguin R, Qureshi Z, Tunçalp Ö, Filippi V. The relationship between insecurity and the quality of hospital care provided to women with abortion-related complications in the Democratic Republic of Congo: A cross-sectional analysis. Int J Gynaecol Obstet 2021; 156 Suppl 1:20-26. [PMID: 34888865 DOI: 10.1002/ijgo.14031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the relationship between insecurity and quality of care provided for abortion complications in high-volume hospitals in the Democratic Republic of Congo (DRC). METHODS Using the WHO Multi-Country Survey on Abortion complications, we analyzed data for 1007 women who received care in 24 facilities in DRC. For inputs of care, we calculated the percentage of facilities in secure and insecure areas meeting 12 readiness criteria for infrastructure and capability. For process and outcomes of care, we estimated the association between security and eight indicators using generalized estimating equation models. RESULTS Facilities in secure areas were more likely to report functioning electricity (93.3% vs 66.7%), availability of an obstetrician 24/7 (42.9% vs 28.6%), and the ability to offer several short-acting contraceptives (83.3% vs 57.1%). However, a higher percentage of facilities in insecure areas reported the availability of a telephone or radio (100% vs 80.0%). Women in insecure areas appeared more likely to experience poor quality clinical care overall than women in secure areas (aOR 2.56; 95% CI, 1.13-5.82, P = 0.03). However, there was no association between security and incomplete medical records (P = 0.20), use of dilatation and curettage (D&C) (P = 0.84), women reporting poor experience of care (P = 0.22), satisfaction with care (P = 0.25), and severe maternal outcomes (P = 0.56). There was weak evidence of an association between security and nonreceipt of contraceptives (P = 0.07), with women in insecure areas 70% less likely to report no contraception (aOR 0.31, 95% CI, 0.09-1.09). Use of D&C was high in secure (43.7%) and insecure (60.4%) areas. CONCLUSION Quality of care did not seem to be very different in secure and insecure areas in DRC, except for some key infrastructure, supply, and human resources elements. The frequent use of D&C for uterine evacuation, the lack of good record keeping, and the lack of contraceptives should be urgently addressed.
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Affiliation(s)
- Jean-José Wolomby-Molondo
- Département de Gynécologie et Obstétrique, Cliniques Universitaires de Kinshasa, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Clara Calvert
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Zahida Qureshi
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - 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
| | - Véronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Miller C. Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910506. [PMID: 34639806 PMCID: PMC8507663 DOI: 10.3390/ijerph181910506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022]
Abstract
It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence—itself from 15 to 20 years ago—suggests that 6–7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70–150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.
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Affiliation(s)
- Calum Miller
- St. Benet's Hall, University of Oxford, Oxford OX1 3LN, UK
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