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Goemans S, Singh A, Yadav AK, McDougal L, Raj A, Averbach SH. The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India. Int J Womens Health 2023; 15:1467-1473. [PMID: 37795194 PMCID: PMC10545903 DOI: 10.2147/ijwh.s414599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 10/06/2023] Open
Abstract
Purpose To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion. Patients and Methods The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India. Results On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18). Conclusion These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.
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Affiliation(s)
- Sophie Goemans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Abhishek Singh
- Department of Public Health & Mortality Studies, International Institute for Population Sciences, Mumbai, Maharashtra, India
- Centre of Demography of Gender, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Ajit Kumar Yadav
- GENDER Project, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Lotus McDougal
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Sarah H Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
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Sigdel A, Angdembe MR, Khanal P, Adhikari N, Maharjan A, Paudel M. Medical abortion drug dispensing practices among private pharmacy workers in Nepal: A mystery client study. PLoS One 2022; 17:e0278132. [PMID: 36417473 PMCID: PMC9683563 DOI: 10.1371/journal.pone.0278132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pharmacies are the first point of contact for women seeking medical abortion (MA) and act as important sources of information and referral in Nepal. Over the counter sale of MA drugs is not currently allowed in Nepal. This study aimed to assess the MA drug dispensing practices of pharmacy workers using mystery clients in Nepal. METHODS A cross-sectional study using the mystery client approach was conducted in 266 pharmacies in September-October 2019. These pharmacies had either received harm reduction training or medical detailing visits. A total of 532 visits were conducted by six male and six female mystery clients. Mystery clients without prescription approached the sample pharmacy and filled out a standard digital survey questionnaire using the SurveyCTO application immediately after each interaction. RESULTS Pharmacy workers dispensed MA drugs in 35.7% of the visits while they refused to provide MA drugs to the mystery clients in 39.3% of visits. Lack of evidence of prior consultation with a physician (27.5%), referral to other health facilities (21.8%), unavailability of MA drugs in the pharmacy (21.3%) and lack of prescription (16.4%) were the main reasons for refusal. Seventy percent of the pharmacy workers inquired clients about last menstrual period/months of pregnancy while 38.1% asked whether the pregnancy status was confirmed. During 65.1% of the visits, mystery clients were told about when to take the MA drugs while in 66.4% of visits, they were told about the route of drug administration. Similarly, mystery clients were briefed about what to expect during the abortion process in half of the visits, and information about the possible side effects of the MA drug was provided in 55.9% of the visits. Pharmacy workers provided correct information on taking MA drugs to mystery clients in 70.7% of visits. CONCLUSION Despite legal provision of sale of MA drugs only on prescription, pharmacy workers dispensed MA drug in one out of three visits. As pharmacies are the initial contacts of women for abortion services in Nepal, correct supplementary information through pharmacy workers can be an effective strategy to expand access to quality safe abortion services.
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Affiliation(s)
- Anil Sigdel
- Population Services International, Lalitpur, Nepal
| | | | - Pratik Khanal
- Population Services International, Lalitpur, Nepal
- * E-mail:
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Shukla A, Vazquez-Quesada L, Vieitez I, Acharya R, RamaRao S. Quality of care in abortion in the era of technological and medical advancements and self-care. Reprod Health 2022; 19:191. [PMID: 36109756 PMCID: PMC9479303 DOI: 10.1186/s12978-022-01499-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities.
Body of text
This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management—especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists).
Conclusions
This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.
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Akinyemi A, Owolabi OO, Erinfolami T, Stillman M, Bankole A. Quality of information offered to women by drug sellers providing medical abortion in Nigeria: Evidence from providers and their clients. Front Glob Womens Health 2022; 3:899662. [PMID: 36060610 PMCID: PMC9428275 DOI: 10.3389/fgwh.2022.899662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Evidence confirmed that the demand for medical abortion (MA) increased significantly during the COVID-19 outbreak in many developing countries including Nigeria. In an abortion-restrictive setting like Nigeria, local pharmacies, and proprietary patent medicine vendors (PPMVs) continue to play a major role in the provision of MA including misoprostol. There is the need to understand these providers' knowledge about the use of misoprostol for abortion and the quality of information they provide to their clients. This analysis is focused on assessing the quality of care provided by both drug seller types, from drug sellers' and women's perspectives. Methodology This study utilized primary data collected from drug sellers (pharmacists and PPMVs) and women across 6 Local Government Areas in Lagos State, Nigeria. The core sample included 126 drug sellers who had sold abortion-inducing drugs and 386 women who procured abortion-inducing drugs from the drug sellers during the time of the study. We calculate quality-of-care indices for the care women received from drug sellers, drawing on WHO guidelines for medication abortion provision. The index based on information from the sellers had two domains—technical competency and information provided to clients, while the index from the women's perspectives includes an additional domain, client experience. Results Results show that the majority of drug sellers in the sample, 56% (n = 70), were pharmacists. However, far more than half of women 60% (n = 233) had visited PPMVs. Overall, the total quality score amongst all drug sellers (mean 0.48, SD0.15) was higher than the total score calculated based on women's responses (mean 0.39, SD 0.21). Using our quality-of-care index, pharmacies and PPMVs seem to have similar technical competency (mean score of 0.23, SD 0.13 in both groups (range 0–1), whilst PPMV's performed better on the information provided to client domain (mean score of 0.79, SD 0.17 compared with pharmacies 0.69, SD 0.25). Based on women's reports, PPMVs scored better on both quality of care domains (technical competency and information provided to clients) compared with pharmacies. Program/Policy Implication In resource-constrained settings such as Nigeria, particularly in the context of health emergencies like COVID-19, there is the need to continue to strengthen and engage PPMVs' capacity and skills in dispensing and administration of MA drugs as a harm reduction strategy. Also, there is the need to target frontline providers in pharmacies for training and skill upscale in MA provision.
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Affiliation(s)
- Akanni Akinyemi
- Center for Research, Evaluation Resources, and Development, Abuja, Nigeria
- Department of Demography and Social Statistics, Obafemi Awolowo University, Ife, Nigeria
- *Correspondence: Akanni Akinyemi
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Singh S, Shekhar C, Bankole A, Acharya R, Audam S, Akinade T. Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model. PLoS One 2022; 17:e0263532. [PMID: 35130319 PMCID: PMC8820640 DOI: 10.1371/journal.pone.0263532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups. METHODS Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste. RESULTS Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous. CONCLUSIONS Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.
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Affiliation(s)
- Susheela Singh
- Guttmacher Institute, New York, New York, United States of America
| | - Chander Shekhar
- Department of Fertility Studies, International Institute for Population Sciences (IIPS), Mumbai, India
| | | | | | - Suzette Audam
- Guttmacher Institute, New York, New York, United States of America
| | - Temitope Akinade
- Guttmacher Institute, New York, New York, United States of America
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Percher J, Saxena M, Srivastava A, Diamond-Smith N. Differential treatment in the provision of medication abortion at pharmacies in Uttar Pradesh, India. AJOG GLOBAL REPORTS 2021; 1:100025. [PMID: 36277455 PMCID: PMC9563544 DOI: 10.1016/j.xagr.2021.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND OBJECTIVE STUDY DESIGN RESULTS CONCLUSION
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Sunil B. Running an obstacle-course: a qualitative study of women's experiences with abortion-seeking in Tamil Nadu, India. Sex Reprod Health Matters 2021; 29:e1966218. [PMID: 34651568 PMCID: PMC8525933 DOI: 10.1080/26410397.2021.1966218] [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] [Indexed: 11/15/2022] Open
Abstract
Irrespective of the legal status of abortion, access to abortion services for women is fraught with numerous challenges across the world. A recent study in India found that most women who had an abortion sought care outside an authorised facility or from a less qualified provider. An analysis of women’s experiences in seeking abortion services would provide a better understanding of the underlying reasons. This paper is based on a qualitative study of the experiences of 16 married women from rural Tamil Nadu, India. The in-depth interviews focused on their pregnancy and childbirth experiences and access to abortion services. The study highlights the obstacle course that women seeking to terminate an unwanted pregnancy have to traverse. Many women were not aware of the legal status of abortion, and frontline workers discouraged them and gave misleading information. The pathways to seeking an abortion were more complex for women from marginalised communities. Providers were judgemental and used delaying tactics or denied abortion services. For the less privileged women, abortion services from government health facilities were conditional on the acceptance of female sterilisation. The providers’ attitudes in government and private health facilities were disrespectful of the women seeking abortion services. To uphold the reproductive and human rights of women who seek abortion services, we need accessible and publicly funded health care services that respect the dignity of all women, are empathetic and uphold women’s right to safe abortion services.
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Kumari S, Kishore J. Medical Termination of Pregnancy (Amendment Bill, 2021): Is it Enough for Indian Women Regarding Comprehensive Abortion Care?? Indian J Community Med 2021; 46:367-369. [PMID: 34759469 PMCID: PMC8575235 DOI: 10.4103/ijcm.ijcm_468_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 04/22/2021] [Indexed: 12/01/2022] Open
Abstract
Medical termination of pregnancy (MTP) has been legalized in India since 1971 considering the huge burden of unsafe abortions. Even after about 50 years, Indian women continued to have unsafe abortions and face adverse and fatal consequences. At this point, only legislative amendments may not be sufficient but along with that, many other aspects need to be considered like awareness, availability, accessibility, affordability of quality MTP services, and contraceptives. People should know the adverse effects of taking unsupervised medical termination pills. Comprehensive abortion care should be provided at every level of health care to ensure the good reproductive health of the women.
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Affiliation(s)
- Sneha Kumari
- Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India
| | - Jugal Kishore
- Department of Community Medicine, VMMC and Safdarjung Hospital, New Delhi, India
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Rodriguez MI, Edelman A, Hersh A, Gartoulla P, Henderson J. Medical abortion offered in pharmacy versus clinic-based settings. Cochrane Database Syst Rev 2021; 6:CD013566. [PMID: 34114643 PMCID: PMC8193989 DOI: 10.1002/14651858.cd013566.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion. OBJECTIVES To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches. SELECTION CRITERIA We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion. MAIN RESULTS Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence). AUTHORS' CONCLUSIONS Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings.
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Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alyssa Hersh
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jillian Henderson
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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Ahmad D, Shankar M, Khanna A, Moreau C, Bell S. Induced Abortion Incidence and Safety in Rajasthan, India: Evidence that Expansion of Services is Needed. Stud Fam Plann 2020; 51:323-342. [PMID: 33270920 DOI: 10.1111/sifp.12140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite induced abortion being broadly legal in India, up-to-date information on its frequency and safety is not readily available. Using direct and indirect methodological approaches, this study measures the one-year incidence and safety of induced abortions among women in the state of Rajasthan. The analysis utilizes data from a population-based survey of 5,832 reproductive aged women who reported on the abortion experiences of their closest female confidante in addition to themselves. We separately assess correlates of having a recent and most unsafe abortion using multivariable regression models. The confidante approach produced a one-year abortion incidence estimate of 23 per 1,000 women, whereas the respondent estimate is 9.5 per 1,000 women. Based on the confidante estimate, approximately 441,000 abortions occurred in Rajasthan over a year. Overall, 25 and 29 percent of respondent and confidante reported abortions were classified as most unsafe. Results suggest that abortion remains an integral component of women's fertility regulation, and that a liberal law alone is insufficient to guarantee access to safe abortion services. Existing policies on abortion in India need updating to permit task sharing in line with current recommendations to expand service delivery so that demand is met through provision of safe and accessible services.
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Affiliation(s)
- Danish Ahmad
- Danish Ahmad, Indian Institute of Health Management Research, 1 Prabhu Dayal Marg, Near Sanganer Airport, Jaipur, 302 029, India
| | - Mridula Shankar
- Mridula Shankar, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Anoop Khanna
- Anoop Khanna, Indian Institute of Health Management Research, Jaipur, India
| | - Caroline Moreau
- Caroline Moreau, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Suzanne Bell
- Suzanne Bell, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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Singh S, Hussain R, Shekhar C, Acharya R, Stillman M, Moore AM. Incidence of treatment for postabortion complications in India, 2015. BMJ Glob Health 2020; 5:e002372. [PMID: 32690482 PMCID: PMC7371025 DOI: 10.1136/bmjgh-2020-002372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 11/05/2022] Open
Abstract
Abortion has been legal under broad criteria in India since 1971. However, access to legal abortion services remains poor. In the past decade, medication abortion (MA) has become widely available in India and use of this method outside of health facilities accounts for over 70% of all abortions. Morbidity from unsafe abortion remains an important health issue. The informal providers who are the primary source of MA may have poor knowledge of the method and may offer inadequate or inaccurate advice on use of the method. Misuse of the method can result in women seeking treatment for true complications as well as during the normal processes of MA. An estimated 5% of all abortions are done using highly unsafe methods and performed by unskilled providers, also contributing to abortion morbidity. This paper provides new representative abortion-related morbidity measures at the national and subnational levels from a large-scale 2015 study of six Indian states-Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh. The outcomes include the number and treatment rates of women with complications resulting from induced abortion and the type of complications. The total number of women treated for abortion complications at the national level is 5.2 million, and the rate is 15.7 per 1000 women of reproductive age per year. In all six study states, a high proportion of all women receiving postabortion care were admitted with incomplete abortion from use of MA-ranging from 33% in Tamil Nadu to 65% in Assam. The paper fills an important gap by providing new evidence that can inform policy-makers and health planners at all levels and lead to improvements in the provision of postabortion care and legal abortion services-improvements that would greatly reduce abortion-related morbidity and its costs to Indian women, their families and the healthcare system.
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Affiliation(s)
| | | | - Chander Shekhar
- Fertility Studies, International Institute for Population Sciences, Mumbai, India
| | | | | | - Ann M Moore
- Research, Guttmacher Institute, New York, New York, USA
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Ferguson I, Scott H. Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1532-1542.e2. [PMID: 32912726 DOI: 10.1016/j.jogc.2020.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety. DATA SOURCES A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL. STUDY SELECTION Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization. DATA EXTRACTION Results for effectiveness, safety, acceptability, and qualitative information were assessed. DATA SYNTHESIS The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion. CONCLUSIONS Mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.
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Gambir K, Kim C, Necastro KA, Ganatra B, Ngo TD. Self-administered versus provider-administered medical abortion. Cochrane Database Syst Rev 2020; 3:CD013181. [PMID: 32150279 PMCID: PMC7062143 DOI: 10.1002/14651858.cd013181.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications. OBJECTIVES To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi2 tests and I2 statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants. AUTHORS' CONCLUSIONS This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.
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Affiliation(s)
- Katherine Gambir
- Population CouncilPoverty, Gender and Youth ProgramOne Dag Hammarskjöld PlazaNew YorkNew YorkUSA10017
| | - Caron Kim
- World Health OrganizationDepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | - Bela Ganatra
- World Health OrganizationDepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Thoai D Ngo
- Population CouncilPoverty, Gender and Youth ProgramOne Dag Hammarskjöld PlazaNew YorkNew YorkUSA10017
- Population CouncilThe GIRL CenterNew YorkNew YorkUSA
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Kagaha A, Manderson L. Medical technologies and abortion care in Eastern Uganda. Soc Sci Med 2020; 247:112813. [PMID: 32058197 PMCID: PMC7613281 DOI: 10.1016/j.socscimed.2020.112813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 11/03/2022]
Abstract
Manual Vacuum Aspirators (MVA), Dilation and Curettage (D&C), and medical abortifacients (Misoprostol, Mifepristone and Divabo) are available in clinical settings that offer abortion and post-abortion care in Uganda. While these technologies imply appropriate and safe abortion care, legal and policy ambiguities impact health outcomes. In this article, we draw on an ethnography of abortion care delivery practice conducted in one district in Eastern Uganda between August 2018 and March 2019, with data from interviews and observations, both of interactions and during quality of care improvement and training meetings. We illuminate how, in the context of a financialized healthcare system and legal restrictions, the meanings and use of medical technologies and abortion care vary across different health facility types. In public health facilities, health workers become state agents in the control of women's bodies. In private health facilities, they become transgressors, who use medical technologies to help women attain termination surreptitiously. Health workers offset risks associated with any involvement in termination, such that pecuniary interests dominate their motivation. Normalized and disciplinary power enact and reproduce unsafe and risky conditions, leading to poor abortion care outcomes. We illustrate the mechanisms of domination and tactics of resistance in abortion care, and expose conditions upon which unsafe and risky outcomes are contingent.
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Affiliation(s)
- Alexander Kagaha
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Institute at Brown for Environment and Society, Brown University, Providence, RI, USA; School of Social Sciences, Monash University, Melbourne, Australia
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Abortion among married young women: findings from a community-based study in Rajasthan and Uttar Pradesh, India. J Biosoc Sci 2019; 52:650-663. [PMID: 31722755 DOI: 10.1017/s0021932019000701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abortion service provision has changed noticeably in the recent past and medication abortion currently accounts for four-fifths of all induced abortions taking place in India. How these changes have modified abortion experiences among young women - a group known to be more disadvantaged than adult women - remains unanswered. This paper fills this gap and examines the experiences of married young abortion seekers, including pre-abortion decision-making, abortion seeking and experiences of the procedure, and post-abortion complications. Data were drawn from a community-based survey of 4952 married young women aged 15-24 years conducted in Uttar Pradesh and Rajasthan in 2015. The study focused on 166 young women who had an induced abortion in the two years before the survey, and used descriptive statistics to describe their abortion experiences. Seventy-four per cent of abortion seekers had relied on medication abortion and 47% had obtained it over the counter without a physician's prescription. Moreover, 90% accessed abortion services from private facilities, including drug sellers. A small proportion (4%) had undergone abortion in the second trimester of pregnancy. At the same time, 13% reported multiple abortion attempts; 17% underwent dilation and curettage; and 52% experienced self-reported complications, including 5% who experienced moderate to severe complications. The findings call for greater attention to providing contraceptive counselling and services to married young women, ensuring abortion services in public health facilities and exploring mechanisms to improve drug sellers' knowledge and practices in providing medication abortion.
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Björnsdottir I, Granas AG, Bradley A, Norris P. A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:13-25. [PMID: 31397533 DOI: 10.1111/ijpp.12570] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 07/09/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide. METHODS We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used. KEY FINDINGS A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study. CONCLUSIONS The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.
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Affiliation(s)
| | | | - Amanda Bradley
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Pauline Norris
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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Moore AM, Stillman M, Shekhar C, Kalyanwala S, Acharya R, Singh S, Pradhan MR, Alagarajan M. Provision of medical methods of abortion in facilities in India in 2015: A six state comparison. Glob Public Health 2019; 14:1757-1769. [PMID: 31339459 DOI: 10.1080/17441692.2019.1642365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Medical methods of abortion, MMA, has been legal in India since 2002. Guidelines stipulate that it should be administered by a provider or acquired via prescription. 1.2 million women having abortions in India use MMA acquired from health facilities [Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., … Browne, A. (2018). The incidence of abortion and unintended pregnancy in India, 2015. The Lancet Global Health, 6(1), e111-e120. doi: 10.1016/S2214-109X(17)30453-9 ]. We undertook a study of abortion in Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh in 2015 to better understand under what conditions and how MMA is being administered in facilities. The majority of facilities that provide MMA are in the private sector and located in urban areas. Most facilities offer MMA both at the facility and as a prescription, although some facilities only offer MMA as a prescription. A high proportion of facilities report that women typically take the medication at home. (Re)training providers in MMA protocols and counselling, increasing the number of facilities offering MMA, and stocking of the drugs would help improve women's access to MMA and the information they need to be able to use this method safely. Key Messages: In the six states in our sample, Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh, 8% of abortions in 2015 were done using medical methods of abortion (MMA) acquired from health facilities. The majority of facilities that provide MMA in the six states are in the private sector and are located in urban areas. Health facilities in Madhya Pradesh and Tamil Nadu are comparatively better in their provision of MMA with Assam, Bihar, Gujarat and Uttar Pradesh demonstrating poorer provision of MMA. There are many opportunities for improvement in the practices of MMA provision through improved training of providers, accessibility to the medications and better support of women using MMA.
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Affiliation(s)
| | | | - Chander Shekhar
- International Institute for Population Sciences , Mumbai , India
| | | | | | | | - Manas R Pradhan
- International Institute for Population Sciences , Mumbai , India
| | - Manoj Alagarajan
- International Institute for Population Sciences , Mumbai , India
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Knowledge, provision of information and barriers to high quality medication abortion provision by pharmacists in Uttar Pradesh, India. BMC Health Serv Res 2019; 19:476. [PMID: 31296200 PMCID: PMC6622002 DOI: 10.1186/s12913-019-4318-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of medication abortion is increasing rapidly in India, the majority of which is purchased through pharmacies. More information is needed about the quality of services provided by pharmacist about medication abortion, especially barriers to providing high quality information. The goal of this study was to explore the quality of pharmacist medication abortion provision using mixed methods to inform the developed of an intervention for this population. METHODS Data was collected via convenience sampling using three methods: a quantitative survey of pharmacists (N = 283), mystery clients (N = 111), and in-depth qualitative interviews with pharmacist (N = 11). Quality indictors from the quantitative data from surveys and mystery clients were compared. Qualitative interviews were used to elucidate reasons behind findings from the quantitative survey. RESULTS Quality of information provided to client purchasing medication abortion was low, especially related to timing and dosing of misoprostol (18% of pharmacists knew correct timing) and side effects (31% not telling any information on side effects). Mystery clients reported lower quality (less correct information) than pharmacists reported about their own behaviors. Qualitative interviews suggested that many barriers exist for pharmacists, including perceptions about what information clients can understand and desire, and also lack of comfort giving certain information to certain types of clients (young women). CONCLUSIONS It is essential to improve the quality of information given to client purchasing medication abortion from pharmacists. Our findings highlight specific gaps in knowledge and reasons for poor quality information. Differences in guidelines available at that time from the Indian Government, World Health Organization, and the medication abortion boxes may lead to confusion amongst pharmacists and potentially clients. Interventions need to improve both knowledge about medication abortion and also biases in the provision of care.
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Srivastava A, Saxena M, Percher J, Diamond-Smith N. Pathways to seeking medication abortion care: A qualitative research in Uttar Pradesh, India. PLoS One 2019; 14:e0216738. [PMID: 31083665 PMCID: PMC6513085 DOI: 10.1371/journal.pone.0216738] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/26/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Abortion is legal in India and medication abortion (MA) using a combined regimen of mifepristone and misoprostol is the preferred method. Users increasingly purchase MA kits directly from pharmacies, in some cases experiencing perceived complications and approaching a facility for care. We present findings of a qualitative research tracing the decision-making pathway(s) of MA users in Uttar Pradesh, India, to help understand knowledge and behaviour gaps, and recommend ways to improve the overall quality of care at these service delivery points. Methods Forty in-depth interviews were conducted with recent MA users (20 each of clinic and pharmacy clients) across three districts. Providers were purposively selected in collaboration with an international organization selling MA kits, using their list of pharmacies and clinics. MA users were identified from the clients of the selected providers, and additionally through the snow ball method. Interviews were conducted in Hindi with verbal informed consent in a private place convenient to the respondent. Transcripts were translated to English and analysed thematically. Results Users first sought MA kits at pharmacies out of convenience, low cost and customer anonymity. Men often purchased kits for their partners and trusted the chemist for guidance on dosage, progression and side effects. For side effects or other concerns after using an MA kit, users first visited their neighbourhood doctor or traditional practitioner. These providers either attempted to treat the issue and failed, or directly advised her to consult a gynaecologist. The final point of care was gynaecologists, preferably female private practitioners with their own clinics. They diagnosed most abortion-related cases as incomplete abortions, emptying the uterus using the dilation and curettage method. Comparatively low cost and convenience made users inclined towards repeat use of MA. Conclusion There are information gaps at various stages in the MA pathway that need to be addressed. Large scale public information programmes are required on safe abortion care- when is it legal, where to obtain MA, dosage, side effects and signs of possible complications. Pharmacists could be trained or incentivized to improve their quality of care to facilitate adequate exchange of information on MA. Since, for most couples, the male partner purchases MA, information approaches or tools are needed that pharmacists can give men to share directly with the MA user.
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Affiliation(s)
- Aradhana Srivastava
- Maternal and Child Health, Public Health Foundation of India, Gurgaon, Haryana, India
- * E-mail:
| | - Malvika Saxena
- Maternal and Child Health, Public Health Foundation of India, Gurgaon, Haryana, India
| | - Joanna Percher
- Bixby Center for Population, Health, and Sustainability, University of California, Berkeley, CA, United States of America
| | - Nadia Diamond-Smith
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, CA, United States of America
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Footman K, Keenan K, Reiss K, Reichwein B, Biswas P, Church K. Medical Abortion Provision by Pharmacies and Drug Sellers in Low- and Middle-Income Countries: A Systematic Review. Stud Fam Plann 2019; 49:57-70. [PMID: 29508948 PMCID: PMC5947709 DOI: 10.1111/sifp.12049] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low‐ and middle‐income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer‐reviewed and grey literature. We double‐extracted data using a standardized template, and double‐graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self‐management in low‐and middle‐income countries.
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Gambir K, Kim C, Necastro KA, Ganatra B, Ngo TD. Self-administered versus provider-administered medical abortion. Hippokratia 2018. [DOI: 10.1002/14651858.cd013181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Katherine Gambir
- Population Council; Poverty, Gender and Youth Program; One Dag Hammarskjöld Plaza New York New York USA 10017
| | - Caron Kim
- World Health Organization; Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Kelly Ann Necastro
- Massachusetts Institute of Technology; Cambridge Massachusetts USA 02139
| | - Bela Ganatra
- World Health Organization; Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Thoai D Ngo
- Population Council; Poverty, Gender and Youth Program; One Dag Hammarskjöld Plaza New York New York USA 10017
- Population Council; The GIRL Center; New York New York USA
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Singh S, Shekhar C, Acharya R, Moore AM, Stillman M, Pradhan MR, Frost JJ, Sahoo H, Alagarajan M, Hussain R, Sundaram A, Vlassoff M, Kalyanwala S, Browne A. The incidence of abortion and unintended pregnancy in India, 2015. LANCET GLOBAL HEALTH 2018; 6:e111-e120. [PMID: 29241602 PMCID: PMC5953198 DOI: 10.1016/s2214-109x(17)30453-9] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/21/2017] [Accepted: 11/13/2017] [Indexed: 11/30/2022]
Abstract
Background Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015. Methods National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4. Findings We estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended. Interpretation Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. Funding Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.
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Affiliation(s)
| | - Chander Shekhar
- International Institute for Population Sciences, Mumbai, India
| | | | | | | | - Manas R Pradhan
- International Institute for Population Sciences, Mumbai, India
| | | | - Harihar Sahoo
- International Institute for Population Sciences, Mumbai, India
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Coast E, Norris AH, Moore AM, Freeman E. Trajectories of women's abortion-related care: A conceptual framework. Soc Sci Med 2018; 200:199-210. [PMID: 29421467 DOI: 10.1016/j.socscimed.2018.01.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 11/16/2022]
Abstract
We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.
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Affiliation(s)
- Ernestina Coast
- Dept. of International Development, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | | | | | - Emily Freeman
- PSSRU, London School of Economics and Political Science, UK
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Rocca CH, Puri M, Shrestha P, Blum M, Maharjan D, Grossman D, Regmi K, Darney PD, Harper CC. Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal. PLoS One 2018; 13:e0191174. [PMID: 29351313 PMCID: PMC5774715 DOI: 10.1371/journal.pone.0191174] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 12/27/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal. METHODS Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression. RESULTS Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]). CONCLUSIONS Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.
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Affiliation(s)
- Corinne H. Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, Oakland, CA, United States of America
- * E-mail:
| | - Mahesh Puri
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Prabhakar Shrestha
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Dev Maharjan
- Center for Research on Environment Health & Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
| | - Daniel Grossman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, Oakland, CA, United States of America
| | | | - Philip D. Darney
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Cynthia C. Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA, United States of America
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Huda FA, Mahmood HR, Alam A, Ahmmed F, Karim F, Sarker BK, Al Haque N, Ahmed A. Provision of menstrual regulation with medication among pharmacies in three municipal districts of Bangladesh: a situation analysis. Contraception 2017; 97:144-151. [PMID: 29175274 DOI: 10.1016/j.contraception.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 11/14/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective was to assess the provision of the combination of mifepristone-misoprostol for menstrual regulation (MR) in randomly selected urban pharmacies in Bangladesh. STUDY DESIGN We conducted a cross-sectional survey among 553 pharmacy workers followed by 548 mystery client visits to the same pharmacies in 3 municipal districts during July 2014-December 2015. RESULTS The survey found that 99% of pharmacy workers visited had knowledge of MR procedures but only two-thirds (67%) could state the legal time limit correctly; they mentioned misoprostol (86%) over mifepristone-misoprostol combination (78%) as a procedure of MR with medication (MRM); 36% reported knowing the recommended dosage of mifepristone-misoprostol combination; 70% reported providing information on effectiveness of the medicines; 50% reported recommending at least one follow-up visit to them; 63% reported explaining possible complications of using the medications; and 47% reported offering any post-MR contraception to their clients. In contrast, mystery client visits found that the mifepristone-misoprostol combination (69%) was suggested over misoprostol (51%) by the pharmacy workers; 54% provided the recommended dosage of mifepristone-misoprostol combination; 42% provided information on its effectiveness; 12% recommended at least one follow-up visit; 11% counseled on possible complications; and only 5% offered post-MR contraceptives to the mystery clients. CONCLUSIONS We found knowledge gaps regarding recommended dosage for MRM and inconsistent practice in informing women on effectiveness, follow-up visits, possible complications and provision of post-MR contraceptives among the pharmacy workers, particularly during the mystery client visits. IMPLICATIONS Pharmacy workers in Bangladesh need to be trained on legal time limits for MR services provision, on providing accurate information on disbursed medicine, and on proper referral mechanisms. A strong monitoring and regulatory system for pharmacy provision of MRM in pharmacies should be established.
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Affiliation(s)
- Fauzia Akhter Huda
- icddr,b: International Centre for Diarrhoeal Disease Research, Bangladesh.
| | | | - Anadil Alam
- icddr,b: International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Faisal Ahmmed
- icddr,b: International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Farzana Karim
- The George Washington University, Washington, DC, USA
| | | | - Nafis Al Haque
- icddr,b: International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Anisuddin Ahmed
- icddr,b: International Centre for Diarrhoeal Disease Research, Bangladesh
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Sjöström S, Essén B, Gemzell-Danielsson K, Klingberg-Allvin M. Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India. BMC MEDICAL EDUCATION 2016; 16:8. [PMID: 26758763 PMCID: PMC4710021 DOI: 10.1186/s12909-016-0532-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 01/06/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education. METHOD We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach. RESULTS The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future. CONCLUSIONS To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.
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Affiliation(s)
- Susanne Sjöström
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Birgitta Essén
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Kristina Gemzell-Danielsson
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Marie Klingberg-Allvin
- />Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- />Department of Women’s and Children’s Health/, International Maternal and Child Health, Uppsala University, 751 85 Uppsala, Sweden
- />School of Health and Social Sciences, Dalarna University, 791 88 Falun, Sweden
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