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

Effectiveness of post-abortion care services to protect women's fertility in China: A systematic review with meta-analysis

OBJECTIVE

This study aimed to evaluate the effectiveness of post-abortion care services in Chinese women who have undergone induced abortion.

METHODS

A systematic literature search was conducted in five databases from January 2011 to June 2023 (PROSPERO registration CRD42023440458). Estimates of intervention effects were represented as relative risk (RR) with 95% confidence intervals (CI). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to evaluate the strength of recommendations.

RESULTS

The meta-analysis of 42 randomized controlled studies involving 70,126 participants indicated that post-abortion care services could significantly increase rate of effective contraceptive use (RR = 2.33, 95%CI = 1.80-3.00, 10 studies, GRADE (Medium)), reduce repeat abortion rate (RR = 0.26, 95%CI = 0.20-0.36, 19 studies, GRADE (High)), increase follow-up visit rate (RR = 1.37, 95%CI = 1.06-1.75, 5 studies, GRADE (Very low)) in one year after abortions, and improve patient satisfaction rate (RR = 1.37, 95%CI = 1.03-1.83, 9 studies, GRADE (High)).

CONCLUSION

Post-abortion care services could help increase the rate of continuation of post-abortion effective contraceptives, prevent repeat abortions, and promote female fertility. Exploring strategies for better provision of post-abortion services requires more high-quality research.

"I will never wish this pain to even my worst enemy": Lived experiences of pain associated with manual vacuum aspiration during post-abortion care in Kenya

BACKGROUND AND OBJECTIVES

In Kenya, where abortion is legally restricted, most abortions are induced using unsafe procedures, and lead to complications treated in public health facilities. The introduction of Manual Vacuum Aspiration (MVA) to treat incomplete abortion has improved the management of abortion complications. However, this technology comes with pain whose management has been a challenge. This paper explores the lived experiences of pain (management) during MVA to document the contributing factors.

METHODS

We used an ethnographic approach to explore girls and healthcare providers' experiences in offering and accessing post-abortion care in Kilifi County, Kenya. The data collection approach included participant observation and informal conversations in public health facilities and neighboring communities, as well as in-depth interviews with 21 girls and young women treated for abortion complication and 12 healthcare providers.

RESULTS

Our findings show that almost all patients described the MVA as the most painful procedure they have ever experienced. The unbearable pain was explained by various factors, including the lack of preparedness of health facilities to offer PAC services (i.e. lack of pain medicine, lack of training, inadequate knowledge and grasp of pain medication guidelines, and malfunctioning MVA kits). Moreover, the attitudes of healthcare providers and facilities management toward the MVA device limited the supply and replacement of MVA kits. Moreover, the scarcity of pain medicines also gave some providers the opportunity to abuse patients guided by their values, whereby they would deny patients pain medication as a form of "punishment" if they were suspected of inducing their abortion, especially adolescent girls.

CONCLUSION

The study findings suggest the need for clearer guidelines on pain medication, value clarification and attitude transformation training for providers, systematizing the use of medical uterine evacuation using medical abortion drug and strengthening the supply chain of pain medication and MVA kits to reduce the pain and improve the quality of post-abortion care.

"They talked to me rudely". Women perspectives on quality of post-abortion care in public health facilities in Kenya

BACKGROUND

Access to safe abortion is legally restricted in Kenya. Therefore, majority women seeking abortion services in such restrictive contexts resort to unsafe methods and procedures that result in complications that often require treatment in health facilities. Most women with abortion-related complications end up in public health facilities. Nevertheless, evidence is limited on the quality of care provided to patients with abortion complications in public health facilities in Kenya.

METHODS

Data for this paper are drawn from a qualitative study that included interviews with 66 women who received post-abortion care in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on mechanisms of decision-making while seeking post-abortion care services, care pathways within facilities, and perceptions of patients on quality of care received including respect, privacy, confidentiality, communication and stigma.

FINDINGS

The participants' perceptions of the quality of care were characterized as either "bad care" or "good care", with the good care focusing on interpersonal aspects such as friendliness, respect, empathy, short waiting time before receiving services, as well as the physical or functional aspects of care such as resolution of morbidity and absence of death. Majority of participants initially reported that they received "good care" because they left the facility with their medical problem resolved. However, when probed, about half of them reported delays in receiving care despite their condition being an emergency (i.e., severe bleeding and pain). Participants also reported instances of abuse (verbal and sexual) or absence of privacy during care and inadequate involvement in decisions around the nature and type of care they received. Our findings also suggest that healthcare providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older). For instance, women who experienced miscarriages reported supportive care whereas women suspected to have induced their abortions felt stigmatized.

CONCLUSION

These findings have far reaching implications on efforts to improve uptake of post-abortion care, care seeking behaviors and on how to assess quality of abortion care. There should be emphasis on interventions meant to enhance processes and structural indicators of post-abortion care services meant to improve patients' experiences throughout the care process. Moreover, more efforts are needed to advance the tools and approaches for assessing women experiences during post-abortion care beyond just the overriding clinical outcomes of care.

Women's perceptions of and experiences with the use of misoprostol for treatment of incomplete abortion in central Malawi: a mixed methods study

BACKGROUND

Abortion-related complications are among the common causes of maternal mortality in Malawi. Misoprostol is recommended for the treatment of first-trimester incomplete abortions but is seldom used for post-abortion care in Malawi.

METHODS

A descriptive cross-sectional study that used mixed methods was conducted in three hospitals in central Malawi. A survey was done on 400 women and in-depth interviews with 24 women receiving misoprostol for incomplete abortion. Convenience and purposive sampling methods were used and data were analysed using STATA 16.0 for quantitative part and thematic analysis for qualitative part.

RESULTS

From the qualitative data, three themes emerged around the following areas: experienced effects, support offered, and women's perceptions. Most women liked misoprostol and reported that the treatment was helpful and effective in expelling retained products of conception. Quantitative data revealed that the majority of participants, 376 (94%) were satisfied with the support received, and 361 (90.3%) believed that misoprostol was better than surgical treatment. The majority of the women 364 (91%) reported they would recommend misoprostol to friends.

CONCLUSIONS

The use of misoprostol for incomplete abortion in Malawi is acceptable and regarded as helpful and satisfactory among women.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

ClinicalTrials.gov NCT03622073.

Supplementary Information

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

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

Experiences of Using Misoprostol in the Management of Incomplete Abortions: A Voice of Healthcare Workers in Central Malawi

Complications after abortion are a major cause of maternal death. Incomplete abortions are common and require treatment with surgical or medical uterine evacuation. Even though misoprostol is a cheaper and safer option, it is rarely used in Malawi. To improve services, an intervention was performed to increase the use of misoprostol in post-abortion care. This study explored healthcare providers' perceptions and experiences with misoprostol in the Malawian setting and their role in achieving effective implementation of the drug. A descriptive phenomenological study was conducted in three hospitals in central Malawi. Focus group discussions were conducted with healthcare workers in centres where the training intervention was offered. Participants were purposefully sampled, and thematic analysis was done. Most of the healthcare workers were positive about the use of misoprostol, knew how to use it and were confident in doing so. The staff preferred misoprostol to surgical treatment because it was perceived safe, effective, easy to use, cost-effective, had few complications, decreased hospital congestion, reduced workload, and saved time. Additionally, misoprostol was administered by nurses/midwives, and not just physicians, thus enhancing task-shifting. The results showed acceptability of misoprostol in post-abortion care among healthcare workers in central Malawi, and further implementation of the drug is recommended.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

Swedish Research Council and THRiVE-2.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Facilitating Uptake of Post-abortion Contraception for Young People in Kenya

Globally, maternal mortality is unacceptably high, and unsafe abortion is the most easily preventable cause of maternal death. Post-abortion contraception, recognized as a High Impact Practice in Family Planning, can reduce rates of unintended pregnancies and unsafe abortion and ultimately save lives. Implementation of this, however, is limited, especially for young people. This case study documents strategies, results, and lessons learned from Planned Parenthood Global's project in South West Kenya, which improved access to and provision of comprehensive abortion care, including safe abortion, post-abortion care and post-abortion contraception, at 80 public and private health facilities. By prioritizing training and mentorship of mid-level providers on both medical and surgical abortion care, post-abortion contraception and youth friendly services, in addition to community engagement and referrals, this intervention removes common barriers to care for women and young people. Eighty-five percent of abortion care clients served by the project accepted same-day contraception, with the vast majority-including 90% of clients aged 24 and under-choosing long-acting reversible contraception. The Closing the Gap project was funded by an anonymous donor.

Peri-abortion contraceptive counseling: A systematic review of randomized controlled trials

Objective

To assess the effects of peri-abortion contraceptive counseling interventions.

Methods

We performed a systematic review of randomized controlled trials (RCTs) that compared the effect of different types of peri-abortion contraceptive counseling interventions and were published as original papers in scientific journals. The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date. Two independent authors identified studies that met the inclusion and exclusion criteria and extracted the data. The risk of bias was assessed using the Cochrane tool, and evidence certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Whenever possible, meta-analyses were performed. The protocol was registered at PROSPERO (CRD42020187354).

Results

Eleven RCTs were eligible for inclusion (published from 2004 to 2017), from which nine compared enhanced versus standard counseling. Pooled estimates showed that, compared to standard counseling, enhanced counseling was associated with a higher incidence of effective contraceptive use (>3 months) (relative risk [RR], 1.12; 95% confidence interval [CI], 1.09–1.16), although no significant difference was found in the incidence of long-acting reversible contraceptive use (RR, 1.25; 95% CI, 0.68–2.29), contraceptive uptake (RR, 1.06; 95% CI, 0.98–1.15), and obstetric event occurrence (RR, 0.91; 95% CI, 0.57–1.47). Certainty of evidence was very low for all outcomes. In addition, two studies compared contraceptive counseling provided by physicians versus that provided by non-physicians, which did not show significant differences.

Conclusions

Enhanced contraceptive counseling may favor effective contraceptive use but may not affect the rate of obstetric event occurrence. Also, the studies did not find a difference in the effects of counseling interventions given by different providers. Since evidence certainty was very low, future well-designed RCTs are needed to make informed decisions.

Registration

The study protocol was registered at PROSPERO (CRD42020187354).

Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest?

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.

Health facility capacity to provide postabortion care in Afghanistan: a cross-sectional study

BACKGROUND

Afghanistan has one of the highest burdens of maternal mortality in the world, estimated at 638 deaths per 100,000 live births in 2017. Infections, obstetric hemorrhage, and unsafe abortion are the three leading causes of maternal death. Contraceptive prevalence rate has fluctuated between 10 and 20% since 2006. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment evaluated facility readiness to provide quality routine and emergency obstetric and newborn care, including postabortion care services.

METHODS

Accessible public health facilities with at least five births per day (n = 77), a nationally representative sample of public health facilities with fewer than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Assessment components examining postabortion care included a facility inventory and record review tool to verify drug, supply, equipment, and facility record availability, and an interview tool to collect information on skilled birth attendants' knowledge and perceptions.

RESULTS

Most facilities had supplies, equipment, and drugs to manage postabortion care, including family planning counseling and services provision. At public facilities, 36% of skilled birth attendants asked to name essential actions to address abortion complications mentioned manual vacuum aspiration (23% at private facilities); fewer than one-quarter mentioned counseling. When asked what information should be given to postabortion clients, 73% described family planning counseling need (70% at private facilities). Nearly all high-volume public health facilities with an average of five or more births per day and less than 5% of low volume public health facilities with an average of 0-4 deliveries per day reported removal of retained products of conception in the past 3 months. Among the 77 high volume facilities assessed, 58 (75%) reported using misoprostol for removal of retained products of conception, 59 (77%) reported using manual vacuum aspiration, and 67 (87%) reported using dilation and curettage.

CONCLUSIONS

This study provides evidence that there is room for improvement in postabortion care services provision in Afghanistan health facilities including post abortion family planning. Access to high-quality postabortion care needs additional investments to improve providers' knowledge and practice, availability of supplies and equipment.

Abortion metrics: a scoping review of abortion measures and indicators

Consensus is lacking on the most appropriate indicators to document progress in safe abortion at programmatic and country level. We conducted a scoping review to provide an extensive summary of abortion indicators used over 10 years (2008–2018) to inform the debate on how progress in the provision and access to abortion care can be best captured. Documents were identified in PubMed and Popline and supplemented by materials identified on major non-governmental organisation websites. We screened 1999 abstracts and seven additional relevant documents. Ultimately, we extracted information on 792 indicators from 142 documents. Using a conceptual framework developed inductively, we grouped indicators into seven domains (social and policy context, abortion access and availability, abortion prevalence and incidence, abortion care, abortion outcomes, abortion impact and characteristics of women) and 40 subdomains. Indicators of access and availability and of the provision of abortion care were the most common. Indicators of outcomes were fewer and focused on physical health, with few measures of psychological well-being and no measures of quality of life or functioning. Similarly, there were few indicators attempting to measure the context, including beliefs and social attitudes at the population level. Most indicators used special studies either in facilities or at population level. The list of indicators (in online supplemental appendix) is an extensive resource for the design of monitoring and evaluation plans of abortion programmes. The large number indicators, many specific to one source only and with similar concepts measured in a multitude of ways, suggest the need for standardisation.

Methods for managing miscarriage: a network meta-analysis

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.

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

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.

Contraceptive uptake among post-abortion care-seeking women with unplanned or planned pregnancy in western Kenya

OBJECTIVES

To investigate contraceptive uptake among PAC-seeking women reporting either planned pregnancies (PP) or unplanned pregnancies (UP) and to identify factors associated with UP.

STUDY DESIGN

This was a sub-study nested in randomised controlled trial (RCT) on women who sought PAC in a low-resource setting in western Kenya. The analysis was based on 807 women who were followed up at 7-10 days and by 472 women at 3 months.

MAIN OUTCOME MEASURES

Descriptive statistics and a binary logistic regression model with odds ratios (OR) and 95% confidence intervals (CI) were used.

RESULTS

Of the 807 women, 375 (46.3%) reported UP, and 432 (53.3%) PP. Most women, regardless of reported pregnancy intention, agreed to start using contraceptive methods: UP 273 (72.8%) and PP 338 (78.2%), respectively, P = 0.072. Independent factors associated with UP were young age (14-20 years; OR 1.177; 95% CI, 1.045-2.818; P = 0.033), unmarried status (OR 9.149; 95% CI, 5.719-14.638; P < 0.001), nulliparity (OR 1.968; 95% CI, 1.287-3.008; P = 0.002), concealed pregnancy (OR 7.708; 95% CI, 3.299-18.012; P < 0.001) and absence of a partner at the clinic visit (OR 3.174; 95% CI, 2.214-4.552; P < 0.001). At 3-month follow-up, there was no difference in contraceptive use between the UP group (161; 77.4%) and the PP group (193; 73.7%), P = 0.350.

CONCLUSION

Contraceptive counselling should be systematically offered to all PAC-seeking women, regardless of their stated pregnancy intention. Adolescents, unmarried women, nulliparous, women with concealed pregnancy and attending the PAC clinic without a partner should be given extra attention by PAC providers offering contraceptive counselling.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

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.

Stigma related to contraceptive use and abortion in Kenya: scale development and validation

BACKGROUND

Stigma related to abortion and contraceptive use is a serious public health threat for young people, and validated scales to measure this stigma are scarce. The purposes of the study were to validate a newly constructed scale to measure the stigma of contraceptive use and to adapt a scale to measure the stigma of abortion.

METHODS

A study nested in a cluster-randomised trial. In 2017, data was collected from 633 secondary school youths, in a semi-urban setting in western Kenya. A qualitative pre-phase (face-validity) were initially utilised to draft and validate a seven-item scale to capture contraceptive use stigma (CUS) and to adapt the Stigmatizing Attitudes, Beliefs and Actions (SABA) scale (18 items), which captures aspects of abortion stigma. Statistical tests used included test-retest reliability analysis, Pearson's correlation coefficients, Wilcoxon signed-rank test, Factor Analysis, Principal Component Analysis, interclass correlation and Cronbach's alpha.

RESULTS

For the CUS scale, paired t-test and Wilcoxon signed-rank test showed no significant score changed between time points (p = 0.64; 0.67). CUS had similar patterns between time points, with two relevant components: promiscuity and lack of autonomy. Cronbach's alpha indicated acceptable internal consistency between time points (0.71;0.7). The confirmatory factor loadings for each item in the modified three subscales of SABA had a similar pattern to the original SABA scale, in particularly regarding negative stereotyping and, excluding and discriminating factors. The Cronbach's alpha was adequate, although lower for the modified SABA (0.74) as compared to the original SABA (0.9). The SABA scale was renamed into Adolescents Stigmatizing Attitudes, Beliefs and Action (ASABA) scale.

CONCLUSIONS

The CUS scale is considered valid and reliable for measuring contraceptive use stigma, and the ASABA scale was rated as reliable for capturing abortion stigma based on negative stereotyping and excluding and discriminating factors. The CUS, up to date the first ever proposed CUS scale, and the ASABA scale can be used to measure effects of stigma reduction interventions with the aim of preventing unintended pregnancies, motherhood and unsafe abortion among adolescents in Kenya and similar low-resource settings.

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

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.

Service provider perceptions of the trend in severity of symptoms and complications in women admitted following an incomplete abortion

Background

Sri Lankan abortion law which dates back to the year 1883, and still unchanged, only allows a legal termination when the mother's life is in danger. Many studies undertaken in the country estimates that even in the light of such a backdrop, and with a high contraceptive prevalence rate, many women attempt an abortion when faced with an unwanted pregnancy. This study aims to describe the changes in abortion-related complications in the country over a period of time and explore the reasons for any changes in severity of symptoms among women hospitalized following an abortion based on the perceptions of healthcare service providers.

Method

Using an interviewer guide, in-depth interviews were carried out among 30 service providers of post abortion care with more than 5 years of experience in obstetrics and gynecology in Sri Lanka.

Results

Service providers perceived that the number of women presenting to hospitals after an induced abortion caused by a mechanical method is minimal or not at all at present. Over time, a significant reduction is seen in the number of women presenting with any abortion-related complications and the severity of complications has also reduced significantly. The common method of termination at present identified by the providers was the use of "drugs" or "the drug - Misoprostol."

Conclusion

Over the years, women appear to have switched from surgical and mechanical methods to medical means (drugs) to induce an abortion and this change has contributed to reduce the severity of complications.

Abortion-related care and the role of the midwife: a global perspective

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.

Contraceptive uptake in post abortion care-Secondary outcomes from a randomised controlled trial, Kisumu, Kenya

Aim

The aim was to explore contraceptive uptake, associated factors and satisfaction among post abortion-care (PAC) seeking women in Kenya. Due to unsafe abortions, almost 120 000 Kenyan women received PAC in 2012, and of these women, 70% did not use contraception before pregnancy.

Methods

This study was nested in a larger randomised controlled trial, where 859 women sought PAC at two public hospitals in Kisumu, in June 2013–May 2016. The women were randomly assigned to a midwife or a physician for PAC, including contraceptive counselling, and followed up at 7–10 days and three months. Associated factors for contraceptive uptake were analysed with binary logistic regression, and contraceptive method choice, adherence and satisfaction level were examined by descriptive statistics, using IBM SPSS Statistics for Windows, Version 22.0.

Results

Out of the 810 PAC-seeking women, 76% (n = 609) accepted the use of contraception. Age groups of 21–25 (OR: 2.35; p < 0.029) and 26–30 (OR: 2.22; p < 0.038), and previous experience of 1–2 gravidities (OR 1.939; p = 0.018) were independent factors associated with the up-take. Methods used: injections 39% (n = 236); pills 27% (n = 166); condoms 25% (n = 151); implant 7% (n = 45) and intrauterine device (IUD) 1% (n = 8). At 3-month follow-up of the women (470/609; 77%), 354 (75%) women still used contraception, and most (n = 332; 94%) were satisfied with the method. Reasons for discontinuation were side-effects (n = 44; 39%), partner refusal (n = 27; 24%), planned pregnancy (n = 27; 24%) and lack of resupplies (n = 15; 13%).

Conclusions

PAC-seeking women seem highly motivated to use contraceptives, yet a quarter decline the use, and at 3-month follow-up a further quarter among the users had discontinued. Implant, IUD and permanent method are rarely used. Strategies to improve contraceptive counselling, particularly to adolescent girls, and to increase access to a wide range of methods, as well as provider training and supervision may help to improve contraceptive acceptance and compliance among PAC-seeking women in Kisumu, Kenya.

Co-creation to scale up provision of simplified high-quality comprehensive abortion care in East Central and Southern Africa

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.

Human rights versus societal norms: a mixed methods study among healthcare providers on social stigma related to adolescent abortion and contraceptive use in Kisumu, Kenya

Introduction

Adolescent pregnancy represents a serious public health issue in sub-Saharan Africa, and stigmatising attitudes are contributing factors. This study investigates stigmatising attitudes related to adolescent pregnancy, abortion and contraceptive use among healthcare providers working with postabortion care (PAC) in a low-resource setting in Kenya.

Methods

A mixed methods approach in a convergent design was utilised to capture attitudes related to abortion and contraceptive use among 86 (f=62; m=19) PAC providers in Kisumu, Kenya. Two Likert-scale questionnaires were used: the 18-item Stigmatising Attitudes, Beliefs and Actions Scale (SABAS) and the 7-item Contraceptive Use Stigma Scale (CUSS). 74 PAC providers responded to the SABAS, 44 to the CUSS and 12 participated in two focus group discussions. Descriptive statistics, psychometric tests of instruments and qualitative content analysis were conducted and reported in accordance with Consolidated Criteria for Reporting Qualitative Research.

Results

Cronbach's α coefficients for the total instrument was 0.88 (SABAS) and 0.84 (CUSS). The majority, 92% (68/74) agreed that a woman who has had an abortion should be treated equally to everyone else, 27% (20/74) considered abortion a sin and 30% (22/74) believed she will make abortion a habit. Contraceptive use among adolescent women was associated with promiscuity (39%; 17/44), hence contraceptives should only be available to married women (36%; 16/44), and 20% (9/44) believed that contraceptive use causes infertility. The providers encouraged women's autonomy and their rights to sexual and reproductive health; however, unclear regulations reinforce religious and cultural beliefs, which hampers implementation of evidence-based contraceptive counselling.

Conclusion

Stigmatising attitudes towards young women in need of abortion and contraception is common among PAC providers. Their work is characterised by a conflict between human rights and societal norms, thus highlighting the need for interventions targeting PAC providers to reduce stigma and misconceptions related to abortion and contraception among adolescent women.