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Endler M, Cleeve A, Sääv I, Gemzell-Danielsson K. How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events. Int J Gynaecol Obstet 2021; 150 Suppl 1:34-42. [PMID: 33219992 PMCID: PMC7539959 DOI: 10.1002/ijgo.13003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.
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Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Sääv
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Simpson JL, Rechitsky S. Preimplantation genetic testing to reduce preterm births in assisted reproductive technology. Int J Gynaecol Obstet 2020; 150:34-40. [PMID: 32524593 DOI: 10.1002/ijgo.13192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/06/2020] [Indexed: 11/12/2022]
Abstract
The 10% rate of preterm birth rate worldwide has not been proved amenable to reduction. Avoiding multiple embryo transfer in assisted reproductive technologies (ART) using in vitro fertilization is one unassailable method. Preimplantation genetic testing (PGT) to select only a single euploid embryo for transfer is one unequivocal way, maintaining 50%-60% pregnancy rates while avoiding twins. Contemporary methodology entails trophectoderm biopsy of a 5-6-day blastocyst, and cryopreservation of biopsied embryos while awaiting analysis by next generation sequencing. Embryo biopsy is safe, analytic validity for chromosomal analysis high, and global access to PGT high.
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Affiliation(s)
- Joe L Simpson
- Department of Obstetrics and Gynecology, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Department of Human and Molecular Genetics, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Reproductive Genetic Innovations, Northbrook, IL, USA
| | - Svetlana Rechitsky
- Department of Human and Molecular Genetics, Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA.,Reproductive Genetic Innovations, Northbrook, IL, USA
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Iyengar K, Klingberg Allvin M, Iyengar SD, Danielsson KG, Essén B. "Who Wants to Go Repeatedly to the Hospital?" Perceptions and Experiences of Simplified Medical Abortion in Rajasthan, India. Glob Qual Nurs Res 2017; 3:2333393616683073. [PMID: 28462355 PMCID: PMC5342849 DOI: 10.1177/2333393616683073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/04/2016] [Accepted: 11/04/2016] [Indexed: 11/17/2022] Open
Abstract
The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.
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Affiliation(s)
- Kirti Iyengar
- Karolinska University Hospital, Stockholm, Sweden.,Action Research and Training for Health, Udaipur, Rajasthan, India
| | | | - Sharad D Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
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Paul M, Essén B, Sariola S, Iyengar S, Soni S, Klingberg Allvin M. Negotiating Collective and Individual Agency: A Qualitative Study of Young Women's Reproductive Health in Rural India. QUALITATIVE HEALTH RESEARCH 2017; 27:311-324. [PMID: 26531879 PMCID: PMC5302084 DOI: 10.1177/1049732315613038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.
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Affiliation(s)
- Mandira Paul
- Uppsala University, Uppsala, Sweden
- Mandira Paul, Department of Women’s and Children’s health/IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
| | | | | | - Sharad Iyengar
- Action Research & Training for Health, Udaipur, Rajasthan, India
| | - Sunita Soni
- Action Research & Training for Health, Udaipur, Rajasthan, India
| | - Marie Klingberg Allvin
- Karolinska Institutet/Karolinska University Hospital, WHO collaborating Centre, Stockholm, Sweden
- Dalarna University, Falun, Sweden
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Paul M, Iyengar SD, Essén B, Gemzell-Danielsson K, Iyengar K, Bring J, Klingberg-Allvin M. Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial. BMC Public Health 2016; 16:1087. [PMID: 27745552 PMCID: PMC5066281 DOI: 10.1186/s12889-016-3726-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 09/27/2016] [Indexed: 11/25/2022] Open
Abstract
Background Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion. Methods A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114). Results There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use. Conclusions Simplified follow-up after early medical abortion will not change women’s opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women’s postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods. Trial registration Clinicaltrials.gov NCT01827995
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Affiliation(s)
- Mandira Paul
- Department of Women's and Children's health / International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Uppsala, Sweden.
| | - Sharad D Iyengar
- Action Research & Training for Health (ARTH), 313011, Udaipur, Rajasthan, India
| | - Birgitta Essén
- Department of Women's and Children's health / International Maternal and Child Health (IMCH), Uppsala University, Akademiska Sjukhuset, Uppsala, SE-751 85, Uppsala, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, WHO collaborating Centre, SE-17176, Stockholm, Sweden
| | - Kirti Iyengar
- Action Research & Training for Health (ARTH), 313011, Udaipur, Rajasthan, India.,Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet and Karolinska University Hospital, WHO collaborating Centre, SE-17176, Stockholm, Sweden
| | | | - Marie Klingberg-Allvin
- Statisticon, SE-10136, Stockholm, Sweden.,School of Education, Health and Social Studies, Dalarna University, SE-791 88, Falun, Sweden
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Iyengar K, Klingberg-Allvin M, Iyengar SD, Paul M, Essén B, Gemzell-Danielsson K. Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial. Acta Obstet Gynecol Scand 2015; 95:173-81. [PMID: 26565074 DOI: 10.1111/aogs.12815] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/25/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol with clinic misoprostol in a low-resource setting. MATERIAL AND METHODS This was a secondary analysis of a randomized controlled trial conducted in six primary care clinics in India. Women seeking medical abortion within up to nine gestational weeks (n = 731) received mifepristone in the clinic and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days. RESULTS Of 731 participants, 73% were from rural areas and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2 and 94.4%, respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion compared with clinic users (79.7%) who would opt for misoprostol at the clinic in a similar situation (p = 0.0002). Ninety-six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience. CONCLUSIONS Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.
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Affiliation(s)
- Kirti Iyengar
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.,Action Research & Training for Health (ARTH), Udaipur, India
| | - Marie Klingberg-Allvin
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.,School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | | | - Mandira Paul
- Department of Women's and Children's Health, Uppsala University, IMCH/Akademiska Sjukhuset, Uppsala, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, Uppsala University, IMCH/Akademiska Sjukhuset, Uppsala, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institute, WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
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Paul M, Iyengar K, Essén B, Gemzell-Danielsson K, Iyengar SD, Bring J, Soni S, Klingberg-Allvin M. Acceptability of Home-Assessment Post Medical Abortion and Medical Abortion in a Low-Resource Setting in Rajasthan, India. Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial. PLoS One 2015; 10:e0133354. [PMID: 26327217 PMCID: PMC4556554 DOI: 10.1371/journal.pone.0133354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/23/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. OBJECTIVE To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India. DESIGN Secondary outcome of a randomised, controlled, non-inferiority trial. SETTING Outpatient primary health care clinics in rural and urban Rajasthan, India. POPULATION Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85 mg/l and were below 18 years. METHODS Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1:1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible. MAIN OUTCOME MEASURES Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups. RESULTS 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001). CONCLUSION Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy. TRIAL REGISTRATION ClinicalTrials.gov NCT01827995.
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Affiliation(s)
- Mandira Paul
- Department of Women’s and Children’s health, Uppsala University, Uppsala, Sweden
| | - Kirti Iyengar
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
- Action Research & Training for Health (ARTH), Udaipur, Rajasthan, India
| | - Birgitta Essén
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
| | - Sharad D. Iyengar
- Action Research & Training for Health (ARTH), Udaipur, Rajasthan, India
| | | | - Sunita Soni
- Action Research & Training for Health (ARTH), Udaipur, Rajasthan, India
| | - Marie Klingberg-Allvin
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, Stockholm, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
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Iyengar K, Paul M, Iyengar SD, Klingberg-Allvin M, Essén B, Bring J, Soni S, Gemzell-Danielsson K. Self-assessment of the outcome of early medical abortion versus clinic follow-up in India: a randomised, controlled, non-inferiority trial. LANCET GLOBAL HEALTH 2015; 3:e537-45. [DOI: 10.1016/s2214-109x(15)00150-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/17/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
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Paul M, Danielsson KG, Essén B, Allvin MK. The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion. Glob Health Action 2015; 8:27512. [PMID: 25828071 PMCID: PMC4380857 DOI: 10.3402/gha.v8.27512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/07/2015] [Accepted: 03/07/2015] [Indexed: 01/23/2023] Open
Abstract
With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.
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Affiliation(s)
- Mandira Paul
- Department of Women's and Children's Health, Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden;
| | - Kristina Gemzell Danielsson
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Birgitta Essén
- Department of Women's and Children's Health, Uppsala University, Akademiska Sjukhuset, Uppsala, Sweden
| | - Marie Klingberg Allvin
- Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
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