1
|
Hefez J, Mulunda JC, Tumba AM, Mpoyi M, Dabash R. Domestication of the Maputo Protocol in the Democratic Republic of Congo: Leveraging regional human rights commitments for abortion decriminalization and access. Int J Gynaecol Obstet 2024; 164 Suppl 1:12-20. [PMID: 38360032 DOI: 10.1002/ijgo.15332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The Maputo Protocol, adopted over 20 years ago, is a promising regional treaty for advancing gender equity and sexual and reproductive health and rights. This instrument has driven progress in women's health and rights across Africa, with much remaining to achieve to realize its full potential for women and girls, including access to safe abortion. The present paper shares the strategies and lessons from the Democratic Republic of Congo's (DRC) reform centered on the domestication of the Protocol, specifically applying its commitments on abortion decriminalization and access. With a vision of addressing maternal mortality and rectifying the impacts of widespread sexual violence against women during war, abortion as a human right and health imperative was at the heart of the DRC's reform. Governmental commitment, broad coalition building, evidence generation, and an intersectional advocacy agenda were critical to overcoming opposition, stigma, and other challenges. This paper shares key learnings from the DRC's complex yet collaborative reform strategies and its processes. The strategy prioritized domestication of the Protocol for numerous reforms, including paving the path to legal abortion on the broad grounds of rape or incest, and saving women's health and/or life. With a commitment to maximizing quality, access, task sharing, and equity, progressive national comprehensive abortion guidelines were created alongside an implementation roadmap for accountability. The DRC's experience leveraging the Maputo Protocol's obligations to advance abortion rights and access offers valuable insights for consideration globally.
Collapse
Affiliation(s)
| | | | - Anne-Marie Tumba
- National Reproductive Health Program (PNSR), Kinshasa, Democratic Republic of Congo
| | - Mike Mpoyi
- Ipas, Kinshasa, Democratic Republic of Congo
| | | |
Collapse
|
2
|
Sorhaindo AM, Castle S, Flomen L, Lathrop E, Mohagheghpour S, Dabash R, Toedtli FK, Wilkins R, Läser L, Titulaer P, Nyamato E, Dakouo ML, Awadallah A, Shrestha R, Morales M, Rehnström Loi U. Adaptations to comprehensive abortion care during the COVID-19 pandemic: case studies of provision in Bolivia, Mali, Nepal, and the occupied Palestinian territory. Sex Reprod Health Matters 2023; 31:2249694. [PMID: 37747711 PMCID: PMC11003643 DOI: 10.1080/26410397.2023.2249694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
The COVID-19 pandemic impacted comprehensive abortion care provision. To maintain access to services while keeping individuals safe from infection, many organisations adapted their programmes. We conducted a programme evaluation to examine service adaptations implemented in Bolivia, Mali, Nepal, and the occupied Palestinian territory. Our programme evaluation used a case study approach to explore four programme adaptations through 14 group and individual interviews among 16 service providers, facility managers and representatives from supporting organisations. Data collection took place between October 2021 and January 2022. We identified adaptations to comprehensive abortion care services in relation to provision, health information systems and counselling, and referrals. Four overarching strategies emerged: (1) the use of digital technologies, (2) home and community outreach, (3) health worker optimisation, and (4) further consideration of groups in vulnerable situations. In Bolivia, the use of a messaging application increased access to confidential gender-based violence support and comprehensive abortion care. In Mali, the adoption of digital approaches created timely and complete data reporting and trained members of the community served as "interlocutors" between the communities and providers. In Nepal, an interim law expanded medical abortion provision to pharmacies, and home visits complemented facility-based services. In the occupied Palestinian territory, the use of a hotline and social media expanded access to quick and reliable information, counselling, referrals, and post-abortion care. Adaptations to comprehensive abortion care service delivery to mitigate disruptions to services during the COVID-19 pandemic may continue to benefit service quality of care, access to care, routine monitoring, as well as inclusivity and communication in the longer term.
Collapse
Affiliation(s)
- Annik Mahalia Sorhaindo
- Technical Consultant, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sarah Castle
- Technical Consultant, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Lola Flomen
- Mixed Health Systems Consultant, Population Services International, WashingtonDC, USA
| | - Eva Lathrop
- Global Medical Director, Population Services International, WashingtonDC, USA
| | - Shirine Mohagheghpour
- Senior Technical Advisor for Service Delivery, Population Services International, WashingtonDC, USA
| | - Rasha Dabash
- Senior Technical Consultant, Ipas, Chapel Hill, NC, USA
| | | | - Rebecca Wilkins
- Technical Lead, Abortion, International Planned Parenthood Federation, London, UK
| | - Laurence Läser
- Technical Officer UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Patricia Titulaer
- Technical Consultant, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ernest Nyamato
- Global Associate Director, Quality of Care, Ipas, Nairobi County, Kenya
| | - Mary Lea Dakouo
- Senior Technical Advisor, Population Services International, Bamako, Mali
| | - Ammal Awadallah
- Executive Director, Palestine Family Planning and Protection Association (PFPPA), Jerusalem, Israel
| | - Raman Shrestha
- Global Evidence and Impact Advisor, Marie Stopes Nepal, Baluwatar, Kathmandu, Nepal
| | - Malena Morales
- Country Director Bolivia, Ipas LAC Region, La Paz, Bolivia
| | - Ulrika Rehnström Loi
- Technical Officer, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211Geneva, Switzerland
| |
Collapse
|
3
|
Shaikh I, Küng SA, Aziz H, Sabir S, Shabbir G, Ahmed M, Dabash R. Telehealth for Addressing Sexual and Reproductive Health and Rights Needs During the COVID-19 Pandemic and Beyond: A Hybrid Telemedicine-Community Accompaniment Model for Abortion and Contraception Services in Pakistan. Front Glob Womens Health 2021; 2:705262. [PMID: 34816237 PMCID: PMC8593931 DOI: 10.3389/fgwh.2021.705262] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
The COVID-19 pandemic led overburdened health care systems to deprioritize essential sexual and reproductive healthcare, including abortion and contraception care, while accelerating shifts in healthcare delivery to digital technologies. However, in many countries, including Pakistan, inequalities in access to digital technologies remain, presenting an opportunity for interventions that both increase access to deprioritized sexual and reproductive health and rights (SRHR) services and overcome the digital divide in delivering digital solutions to those in need of SRHR services. In June 2020, Ipas Pakistan partnered with Sehat Kahani (SK), a local health care NGO and telehealth service, and an existing network of Lady Health Workers (LHWs) to launch a novel hybrid telemedicine-community accompaniment pilot. The model linked women via LHWs with mobile devices to online providers for telemedicine consultations for SRH, including abortion services, contraception, and other gynecological consultations. In June 2020, we trained 98 LHWs and 22 telehealth doctors. Between June 2020 and March 2021, a total of 176 women were referred by LHWs for telehealth consultations. Among women who received abortion services, nearly all (90%) reported complete uterine evacuation. No serious adverse events were reported. Overall satisfaction was high; 81% reported being satisfied, and 86% said it is likely they would recommend the telehealth service to others. Data show that the provision of SRHR services via a telehealth-accompaniment model can be successfully implemented in Pakistan. Outcome data show high satisfaction and good clinical outcomes for women accessing care through this model. However, more data are needed to understand the full potential of this model. Barriers to digital health models, such as poor or inconsistent internet access, remain in places like Pakistan, especially in rural settings. This approach has its limitations but should be considered as an option in settings with similarly established community health networks and inequitable access to digital health.
Collapse
|
4
|
Kapp N, Edelman A, Gomperts R, Srinivasan K, Dabash R. Addressing the urgent global need for later abortion care during COVID-19 and beyond. BMJ Sex Reprod Health 2021; 47:e15. [PMID: 33504511 PMCID: PMC8515098 DOI: 10.1136/bmjsrh-2020-200945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 06/12/2023]
Affiliation(s)
| | - Alison Edelman
- Oregon Health & Science University, Portland, Oregon, USA
| | - Rebecca Gomperts
- Women on Web International Foundation, Amsterdam, The Netherlands
| | | | | |
Collapse
|
5
|
Anger HA, Durocher J, Dabash R, Hassanein N, Ononge S, Burkhardt G, Frye LJ, Diop A, Beye Diop SBM, Darwish E, Ramadan MC, Kayaga J, Charles D, Gaye A, Eckardt M, Winikoff B. Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade. PLoS One 2021; 16:e0245988. [PMID: 33556104 PMCID: PMC7869979 DOI: 10.1371/journal.pone.0245988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objective We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care. Methods This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported. Results Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable. Conclusion UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.
Collapse
Affiliation(s)
- Holly A. Anger
- Gynuity Health Projects, New York, New York, United States of America
- * E-mail:
| | - Jill Durocher
- Gynuity Health Projects, New York, New York, United States of America
| | - Rasha Dabash
- Gynuity Health Projects, New York, New York, United States of America
| | | | - Sam Ononge
- Makerere University School of Health Sciences, Kampala, Uganda
| | - Gillian Burkhardt
- Gynuity Health Projects, New York, New York, United States of America
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, United States of America
| | - Laura J. Frye
- Gynuity Health Projects, New York, New York, United States of America
| | - Ayisha Diop
- Gynuity Health Projects, New York, New York, United States of America
| | | | - Emad Darwish
- Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | - Dyanna Charles
- Gynuity Health Projects, New York, New York, United States of America
| | - Alioune Gaye
- Obstetrician/Gynecologist Consultant, Dakar, Senegal
| | - Melody Eckardt
- Global Health Innovation Lab, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Beverly Winikoff
- Gynuity Health Projects, New York, New York, United States of America
| |
Collapse
|
6
|
Mary M, Jafarey S, Dabash R, Kamal I, Rabbani A, Abbas D, Durocher J, Tan YL, Winikoff B. The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan. Matern Child Health J 2020; 25:118-126. [PMID: 33242210 PMCID: PMC7822773 DOI: 10.1007/s10995-020-03047-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 12/03/2022]
Abstract
Objective To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births. Methods A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits. Participants and their families received educational materials and were counseled on how to diagnose excessive bleeding and the importance of seeking care at a facility if PPH occurs. In the intervention phase, participants were also given misoprostol and counselled on how to administer the four 200 mcg tablets for first aid in case of PPH. Participants were followed-up postpartum to collect data on use of misoprostol for Family First Aid at home deliveries (primary outcome) and record maternal and perinatal outcomes. Results Of the 4008 participants enrolled, 97% were successfully followed-up postpartum. Half of the participants in each phase delivered at home. Among home deliveries, the odds of reporting PPH almost doubled among in the intervention phase (OR 1.98; CI 1.43, 2.76). Among those reporting PPH, women in the intervention phase were significantly more likely to have received PPH treatment (OR 10.49; CI 3.37, 32.71) and 90% administered the dose correctly. No maternal deaths, invasive procedures or surgery were reported in either phase after home deliveries. Conclusions The Family First Aid approach is a safe and feasible model of care that provides timely PPH treatment to women delivering at home in rural communities.
Collapse
Affiliation(s)
- Meighan Mary
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA.
| | - Sadiqua Jafarey
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Rasha Dabash
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Imtiaz Kamal
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Arjumand Rabbani
- National Committee for Maternal and Neonatal Health, Karachi, Pakistan
| | - Dina Abbas
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Jill Durocher
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Yi-Ling Tan
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street Suite 710, New York, NY, 10017, USA
| |
Collapse
|
7
|
Anger HA, Dabash R, Hassanein N, Darwish E, Ramadan MC, Nawar M, Charles D, Breebaart M, Winikoff B. A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt. BMC Pregnancy Childbirth 2020; 20:317. [PMID: 32448257 PMCID: PMC7245883 DOI: 10.1186/s12884-020-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed. Methods This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt. Two PPH management approaches were compared: 1) 600mcg oral misoprostol given to all women after delivery (i.e. primary prevention, current standard of care); 2) 800mcg sublingual misoprostol given only to women with 350-500 ml postpartum blood loss estimated using an underpad (i.e. secondary prevention). The primary outcome was mean change in pre- and post-delivery hemoglobin. Secondary outcomes included hemoglobin ≥2 g/dL and other PPH interventions. Results Misoprostol was administered after delivery to 100% (1555/1555) and 10.7% (117/1099) of women in primary and secondary prevention clusters, respectively. The mean drop in pre- to post-delivery hemoglobin was 0.37 (SD: 0.91) and 0.45 (SD: 0.76) among women in primary and secondary prevention clusters, respectively (difference adjusted for clustering = 0.01, one-sided 95% CI: < 0.27, p = 0.535). There were no statistically significant differences in secondary outcomes, including hemoglobin drop ≥2 g/dL, PPH diagnosis, transfer to higher level, or other interventions. Conclusions Misoprostol for secondary prevention of PPH is comparable to universal prophylaxis and can be implemented using local materials, such as underpads. Trial registration Clinicaltrials.gov NCT02226588, date of registration 27 August 2014.
Collapse
Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA.
| | - Rasha Dabash
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Emad Darwish
- Faculty of Medicine, Alexandria University, 17 Champollion St, El Messalah, Alexandria, Egypt
| | | | - Medhat Nawar
- El Beheira Governorate, Ministry of Health and Population, Damanhour, Egypt
| | - Dyanna Charles
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| |
Collapse
|
8
|
Anger HA, Dabash R, Durocher J, Hassanein N, Ononge S, Frye LJ, Diop A, Beye SB, Burkhardt G, Darwish E, Ramadan MC, Kayaga J, Charles D, Gaye A, Eckardt M, Winikoff B. The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum haemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped wedge, cluster-randomised trial. BJOG 2019; 126:1612-1621. [PMID: 31410966 PMCID: PMC6899652 DOI: 10.1111/1471-0528.15903] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To assess the effectiveness of introducing condom-catheter uterine balloon tamponade (UBT) for postpartum haemorrhage (PPH) management in low- and middle-income settings. DESIGN Stepped wedge, cluster-randomised trial. SETTING Eighteen secondary-level hospitals in Uganda, Egypt and Senegal. POPULATION Women with vaginal delivery from October 2016 to March 2018. METHODS Use of condom-catheter UBT for PPH management was introduced using a half-day training and provision of pre-packaged UBT kits. Hospitals were randomised to when UBT was introduced. The incident rate (IR) of study outcomes was compared in the control (i.e. before UBT) and intervention (i.e. after UBT) periods. Mixed effects regression models accounted for clustering (random effect) and time period (fixed effect). MAIN OUTCOME MEASURES Combined IR of PPH-related invasive surgery and/or maternal death. RESULTS There were 28 183 and 31 928 deliveries in the control and intervention periods, respectively. UBT was used for 9/1357 and 55/1037 women diagnosed with PPH in control and intervention periods, respectively. PPH-related surgery or maternal death occurred in 19 women in the control period (IR = 6.7/10 000 deliveries) and 37 in the intervention period (IR = 11.6/10 000 deliveries). The adjusted IR ratio was 4.08 (95% confidence interval 1.07-15.58). Secondary outcomes, including rates of transfer and blood transfusion, were similar in the trial periods. CONCLUSIONS Introduction of condom-catheter UBT in these settings did not improve maternal outcomes and was associated with an increase in the combined incidence of PPH-related surgery and maternal death. The lack of demonstrated benefit of UBT introduction with respect to severe outcomes warrants reflection on its role. TWEETABLE ABSTRACT Stepped wedge trial shows UBT introduction does not reduce the combined incidence of PPH-related surgery or death.
Collapse
Affiliation(s)
- H A Anger
- Gynuity Health Projects, New York, NY, USA
| | - R Dabash
- Gynuity Health Projects, New York, NY, USA
| | - J Durocher
- Gynuity Health Projects, New York, NY, USA
| | - N Hassanein
- Obstetrician/Gynaecologist consultant, Alexandria, Egypt
| | - S Ononge
- Makerere University School of Health Sciences, Kampala, Uganda
| | - L J Frye
- Gynuity Health Projects, New York, NY, USA
| | - A Diop
- Gynuity Health Projects, New York, NY, USA
| | - S B Beye
- Centre De Santé Philippe Senghor, Dakar, Senegal
| | | | - E Darwish
- Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - M C Ramadan
- El Galaa Maternity Teaching Hospital, Cairo, Egypt
| | - J Kayaga
- Global Health Uganda, Kampala, Uganda
| | - D Charles
- Gynuity Health Projects, New York, NY, USA
| | - A Gaye
- Obstetrician/Gynaecologist, Dakar, Senegal
| | - M Eckardt
- Division of Global Health Innovation, Massachusetts General Hospital, Boston, MA, USA
| | - B Winikoff
- Gynuity Health Projects, New York, NY, USA
| |
Collapse
|
9
|
Anger H, Durocher J, Dabash R, Winikoff B. How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin? PLoS One 2019; 14:e0221216. [PMID: 31437195 PMCID: PMC6705817 DOI: 10.1371/journal.pone.0221216] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022] Open
Abstract
Objective We aimed to better understand how well postpartum blood loss and common postpartum hemorrhage (PPH) definitions (i.e. blood loss ≥500ml = PPH, ≥1000ml = “severe” PPH) correlate with postpartum anemia and fall in hemoglobin. Methods Secondary analysis of data from three randomized trials that objectively measured postpartum blood loss and pre- and post-delivery hemoglobin among vaginal deliveries: one trial included 1056 home-births in Pakistan and two multi-country hospital-based trials included 1279 women diagnosed with PPH. We calculated Spearman’s correlation coefficients (rs) for blood loss with hemoglobin drop and postpartum hemoglobin, and we compared PPH blood loss markers (≥500ml, ≥1000ml) with large hemoglobin drops (≥2 g/dL) and the threshold for moderate postpartum anemia (<10g/dL). Results In the Pakistan study and the multi-country trials, blood loss was weakly correlated with hemoglobin drop (Pakistan: rs = -0.220, multi-country trials: rs = -0.271) and postpartum hemoglobin (Pakistan: rs = -0.220, multi-country trials: rs = -0.316). In both the Pakistan and multi-country trials, hemoglobin drop ≥2 g/dL occurred in less than half of women with 500–999 ml blood loss (55/175 [31%] and 302/725 [42%], respectively) and was more common among women who bled ≥1000ml (19/28 [68%] and 347/554 [63%], respectively). Similarly, in the Pakistan and multi-country trials, postpartum anemia <10 g/dL was less frequent among women who bled 500–999 ml (55/175 [31%] and 390/725 [54%], respectively) and more frequent among women with ≥1000ml blood loss (20/28 [71%] and 416/554 [75%], respectively). Conclusions Postpartum morbidity as measured by hemoglobin markers was common for women with blood loss ≥1000ml and relatively infrequent among women with blood loss 500-999ml. These findings reinforce the importance of severe PPH as the preferred outcome to be used in research. The weak correlation between blood loss and hemoglobin markers also suggests that this relationship is not straightforward and should be carefully interpreted.
Collapse
Affiliation(s)
- Holly Anger
- Gynuity Health Projects, New York, NY, United States of America
- * E-mail:
| | - Jill Durocher
- Gynuity Health Projects, New York, NY, United States of America
| | - Rasha Dabash
- Gynuity Health Projects, New York, NY, United States of America
| | | |
Collapse
|
10
|
Charles D, Anger H, Dabash R, Darwish E, Ramadan MC, Mansy A, Salem Y, Dzuba IG, Byrne ME, Breebaart M, Winikoff B. Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial. BMC Pregnancy Childbirth 2019; 19:38. [PMID: 30658605 PMCID: PMC6339323 DOI: 10.1186/s12884-019-2181-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 01/07/2019] [Indexed: 12/20/2022] Open
Abstract
Background Oxytocin for postpartum hemorrhage (PPH) prophylaxis is commonly administered by either intramuscular (IM) injection or intravenous (IV) infusion with both routes recommended equally and little discussion of potential differences between the two. This trial assesses the effectiveness and safety of 10 IU oxytocin administered as IM injection versus IV infusion and IV bolus during the third stage of labor for PPH prophylaxis. Methods In two tertiary level Egyptian maternity hospitals, women delivering vaginally without exposure to pre-delivery uterotonics were randomized to one of three prophylactic oxytocin administration groups after delivery of the baby. Blood loss was measured 1 h after delivery, and side effects were recorded. Primary outcomes were mean postpartum blood loss and proportion of women with postpartum blood loss ≥500 ml in this open-label, three-arm, parallel, randomized controlled trial. Results Four thousand nine hundred thirteen eligible, consenting women were randomized. Compared to IM injection, mean blood loss was 5.9% less in the IV infusion arm (95% CI: -8.5, − 3.3) and 11.1% less in the IV bolus arm (95% CI: -14.7, − 7.8). Risk of postpartum blood loss ≥500 ml in the IV infusion arm was significantly less compared to IM injection (0.8% vs. 1.5%, RR = 0.50, 95% CI: 0.27, 0.91). No side effects were reported in any arm. Conclusions Intravenous oxytocin is more effective than intramuscular injection for the prevention of PPH in the third stage of labor. Oxytocin delivered by IV bolus presents no safety concerns after vaginal delivery and should be considered a safe option for PPH prophylaxis. Trial registration clinicaltrials.gov #NCT01914419, posted August 2, 2013.
Collapse
Affiliation(s)
- Dyanna Charles
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA.
| | - Holly Anger
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA
| | - Rasha Dabash
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA
| | - Emad Darwish
- Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt
| | | | - Amr Mansy
- Shatby Maternity Hospital, Alexandria University, Alexandria, Egypt
| | - Yomna Salem
- El Galaa Teaching Hospital, 41 El-Galaa, Cairo, Egypt
| | - Ilana G Dzuba
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA
| | - Meagan E Byrne
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA
| | - Miral Breebaart
- Independent Consultant, 16B Dr. Mostafa el Diwani, Garden City, Cairo, Egypt
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd St, Suite 710, New York, NY, 10010, USA
| |
Collapse
|
11
|
Anger H, Dabash R, Peña M, Coutiño D, Bousiéguez M, Sanhueza P, Winikoff B. Use of an at-home multilevel pregnancy test and an automated call-in system to follow-up the outcome of medical abortion. Int J Gynaecol Obstet 2018; 144:97-102. [DOI: 10.1002/ijgo.12679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/10/2018] [Accepted: 09/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Dolores Coutiño
- Hospital Materno-Infantil Nicolás M. Cedillo; Secretariat of Health; Mexico City Mexico
| | | | - Patricio Sanhueza
- Department of Reproductive Health; Secretariat of Health; Mexico City Mexico
| | | |
Collapse
|
12
|
Morris JL, Winikoff B, Dabash R, Weeks A, Faundes A, Gemzell-Danielsson K, Kapp N, Castleman L, Kim C, Ho PC, Visser GH. FIGO's updated recommendations for misoprostol used alone in gynecology and obstetrics. Int J Gynaecol Obstet 2017. [DOI: 10.1002/ijgo.12181] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | | | | | - Andrew Weeks
- Department of Women's and Children's Health; University of Liverpool; Liverpool UK
| | - Anibal Faundes
- Department of Obstetrics and Gynecology; University of Campinas; São Paulo Brazil
| | | | | | - Laura Castleman
- Ipas; Chapel Hill NC USA
- University of Michigan; Ann Arbor MI USA
| | | | | | | |
Collapse
|
13
|
Raymond EG, Shochet T, Blum J, Sheldon WR, Platais I, Bracken H, Dabash R, Weaver MA, Ngoc NTN, Blumenthal PD, Winikoff B. Serial multilevel urine pregnancy testing to assess medical abortion outcome: a meta-analysis. Contraception 2017; 95:442-448. [DOI: 10.1016/j.contraception.2016.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 01/21/2023]
|
14
|
Dabash R, Chong E, Bracken H, Tsereteli T, Abrahamyan R, Hajri S, Karki C, Sfar E, Kurbanbekova D, Bajracharya J, Sadikova D, Shochet T, Platais I, Tan Y, Murtagh C, Winikoff B. A randomized controlled trial comparing repeat doses of 400 mcg sublingual to buccal misoprostol after mifepristone for termination of pregnancy 13–21 weeks. Contraception 2017. [DOI: 10.1016/j.contraception.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
15
|
Dabash R, Shochet T, Hajri S, Chelli H, Hassairi AE, Haleb D, Labassi H, Sfar E, Temimi F, Koenig L, Winikoff B. Self-administered multi-level pregnancy tests in simplified follow-up of medical abortion in Tunisia. BMC Women's Health 2016; 16:49. [PMID: 27475998 PMCID: PMC4967516 DOI: 10.1186/s12905-016-0327-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/22/2016] [Indexed: 11/22/2022]
Abstract
Background This study was conducted to assess the efficacy and acceptability of using a multi-level pregnancy test (MLPT) combined with telephone follow-up for medical abortion in Tunisia, where the majority of providers are midwives. Methods Four hundred and four women with gestational age ≤ 70 days’ LMP seeking medical abortion at six study sites were enrolled in this open-label trial. Participants administered a baseline MLPT at the clinic prior to mifepristone administration and were asked to take a second MLPT at home and to call in its results before returning the day of their scheduled follow-up visit 10-14 days later. Results Almost all women with follow-up (97.1 %, n = 332/342) had successful abortions without the need for surgical intervention. The MLPT worked extremely well among women ≤63 days’ LMP in ruling out ongoing pregnancy (negative predictive value (NPV) =100 % (n = 298/298)) and also detecting women with ongoing pregnancies (sensitivity = 100 %; 2/2) as needing follow-up due to non-declining hCG. Among women 64-70 days’ LMP, the test also worked well in ruling out ongoing pregnancy (NPV = 96.9 % (n = 31/32) but not as well in terms of sensitivity (50 %), with only one of two ongoing pregnancies detected by MLPT as needing follow-up. Most women (95.1 %) found the MLPT to be very easy or easy to use and would consider using the MLPT again (97.4 %) if needed. Conclusions Self-administered pre and post MLPT are very easy for women to use and accurate in assessing medical abortion success up to 63 days’ LMP. MLPT use for medical abortion follow-up has the potential to facilitate task sharing services and eliminate the burden of routine in-person follow-up visits for the large majority of women. Additional research is warranted to explore the accuracy of the MLPT in identifying ongoing pregnancy among women with gestational ages > 63 days. Trial registration This study was registered on May 13, 2010, on clinicaltrials.gov as NCT01150279.
Collapse
Affiliation(s)
- Rasha Dabash
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Tara Shochet
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | | | | | | | | | - Hayet Labassi
- Office National de la Famille et de la Population, Tunis, Tunisia
| | - Ezzedine Sfar
- Centre de Maternite et de Neonatologie de La Rabta, Tunis, Tunisia
| | - Fatma Temimi
- Office National de la Famille et de la Population, Tunis, Tunisia
| | - Leah Koenig
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| |
Collapse
|
16
|
Raghavan S, Geller S, Miller S, Goudar SS, Anger H, Yadavannavar MC, Dabash R, Bidri SR, Gudadinni MR, Udgiri R, Koch AR, Bellad MB, Winikoff B. Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial. BJOG 2016; 123:120-7. [PMID: 26333044 PMCID: PMC5014137 DOI: 10.1111/1471-0528.13540] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis. DESIGN A cluster-randomised non-inferiority community trial. SETTING Health sub-centres and home deliveries in the Bijapur district of Karnataka, India. POPULATION Women with low-risk pregnancies who were eligible for delivery with an Auxiliary Nurse Midwife at home or sub-centre and who consented to be part of the study. METHODS Auxiliary Nurse Midwifes were randomised to secondary prevention using 800 mcg sublingual misoprostol administered to women with postpartum blood loss ≥350 ml or to universal prophylaxis using 600 mcg oral misoprostol administered to all women during the third stage of labour. MAIN OUTCOME MEASURES Postpartum haemoglobin ≤7.8 g/dl, mean postpartum blood loss and postpartum haemoglobin, postpartum haemorrhage rate, transfer to higher-level facilities, acceptability and feasibility of the intervention. RESULTS Misoprostol was administered to 99.7% of women as primary prevention. In secondary prevention, 92 (4.7%) women had postpartum bleeding ≥350 ml, of which 90 (97.8%) received misoprostol. The proportion of women with postpartum haemoglobin ≤7.8 g/dl was 5.9 and 8.8% in secondary and primary prevention clusters, respectively [difference -2.9%, one-sided 95% confidence interval (CI) <1.3%]. Postpartum transfer and haemorrhage rates were low (<1%) in both groups. Shivering was more common in primary prevention clusters (P = 0.013). CONCLUSION Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis based on the primary outcome of postpartum haemoglobin. Secondary prevention could be a good alternative to universal prophylaxis as it medicates fewer women and is an acceptable and feasible strategy at the community level. TWEETABLE ABSTRACT Secondary prevention of postpartum haemorrhage with misoprostol is non-inferior to universal prophylaxis.
Collapse
Affiliation(s)
| | - S Geller
- University of Illinois at ChicagoChicagoILUSA
| | - S Miller
- University of CaliforniaSan FranciscoCAUSA
| | - SS Goudar
- KLE University's Jawaharlal Nehru Medical CollegeBelgaumIndia
| | - H Anger
- Gynuity Health ProjectsNew YorkNYUSA
| | - MC Yadavannavar
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - R Dabash
- Gynuity Health ProjectsNew YorkNYUSA
| | - SR Bidri
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - MR Gudadinni
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - R Udgiri
- BLDE University's Sri B. M. Patil Medical CollegeBijapurIndia
| | - AR Koch
- University of Illinois at ChicagoChicagoILUSA
| | - MB Bellad
- KLE University's Jawaharlal Nehru Medical CollegeBelgaumIndia
| | | |
Collapse
|
17
|
Shochet T, Blum J, Blumenthal P, Bracken H, Dabash R, Platais I, Sheldon W, Winikoff B. Use of a semiquantitative pregnancy test (SQPT) for medical abortion follow-up. Contraception 2015. [DOI: 10.1016/j.contraception.2015.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
18
|
Bracken H, Dabash R, Tsertsvadze G, Posohova S, Shah M, Hajri S, Mundle S, Chelli H, Zeramdini D, Tsereteli T, Platais I, Winikoff B. A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days' LMP: a prospective comparative open-label trial. Contraception 2014; 89:181-6. [DOI: 10.1016/j.contraception.2013.10.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
|
19
|
Swica Y, Raghavan S, Bracken H, Dabash R, Winikoff B. Review of the literature on patient satisfaction with early medical abortion using mifepristone and misoprostol. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.11.37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
20
|
Dabash R, Ben Attia M, Temimi F, Hajri S, Conkling K, Winikoff B. O294 NATIONAL EXPANSION STUDY OF MEDICAL ABORTION TO 63 DAYS LMP IN TUNISIAN FAMILY PLANNING CLINICS. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Dabash R. I081 DOES ROUTE MATTER? WHAT WE KNOW ABOUT FIRST TRIMESTER MEDICAL ABORTION OUTCOMES WITH REGIMENS USING VARIOUS ROUTES OF MISOPROSTOL ADMINISTRATION. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60111-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Dabash R. I080 PROGRAMMATIC IMPLICATIONS OF CURRENT STRATEGIES AND NEW APPROACHES TO INTEGRATING MISOPROSTOL FOR PPH MANAGEMENT. Int J Gynaecol Obstet 2012. [DOI: 10.1016/s0020-7292(12)60110-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
23
|
Abstract
Excessive postpartum hemorrhage (PPH) is a leading cause of maternal death globally. Current approaches to address PPH at the community level focus on reducing the incidence of PPH, but often fail to address the issue of PPH treatment. Given that institutional delivery is not yet a reality for all women, comprehensive care for excessive bleeding after delivery needs to be available at the community level. A new hybrid model of "secondary prevention"-presumptive treatment for women with more than average blood loss-presents one alternative community-based approach. If shown to be effective and feasible, this approach could support policy changes and avoid the need to provide uterotonics to all women after delivery. This Special Communication discusses some of the benefits and limitations of current community approaches using misoprostol for PPH prevention and explains why it is now opportune to translate clinical knowledge into pragmatic PPH service delivery strategies.
Collapse
Affiliation(s)
- Rasha Dabash
- Gynuity Health Projects, New York, NY 10010, USA.
| | | | | | | | | |
Collapse
|
24
|
Blum J, Ngoc NTN, Ragjavem S, Nga NTB, Dabash R, Diop A, Winikoff B. Response to Letter to the Editor. Contraception 2012. [DOI: 10.1016/j.contraception.2011.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
Ngoc NTN, Blum J, Raghavan S, Nga NTB, Dabash R, Diop A, Winikoff B. Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone. Contraception 2011; 83:410-7. [DOI: 10.1016/j.contraception.2010.09.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 09/02/2010] [Accepted: 09/04/2010] [Indexed: 11/16/2022]
|
26
|
Dabash R, Ramadan MC, Darwish E, Hassanein N, Blum J, Winikoff B. A randomized controlled trial of 400-μg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals. Int J Gynaecol Obstet 2011; 111:131-5. [PMID: 20801444 DOI: 10.1016/j.ijgo.2010.06.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/02/2010] [Accepted: 07/20/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the safety, efficacy, and acceptability of 400-μg sublingual misoprostol with that of manual vacuum aspiration (MVA) in 2 Egyptian hospitals. METHODS Participating women were randomized to either MVA or misoprostol treatment for incomplete abortion. The primary outcome, complete uterine evacuation, was determined 1 week later, as were adverse effects, change in hemoglobin, acceptability, and satisfaction. RESULTS Complete uterine evacuation was achieved in 98.3% of women who received misoprostol and 99.7% who underwent MVA (relative risk [RR] 0.99; 95% confidence interval [CI], 0.97-1.00). A decrease in hemoglobin of 2g/dL or more was comparably rare in the 2 groups (0.3% misoprostol vs 0.9% MVA; RR 0.34 [95% CI, 0.04-3.21]). Mean change in hemoglobin was also clinically similar (-0.5 g/dL misoprostol vs -0.4 g/dL MVA; P<0.01). Heavy bleeding was rare (2.4% misoprostol vs 1.6% MVA; RR 1.55 [95% CI, 0.51-4.68]) following treatment. Nearly all women (96.8% misoprostol vs 98.3% MVA) were satisfied with their treatment but those who received misoprostol were significantly more likely to prefer that method in the future (81.9% vs 62.8%; RR 1.30 [95% CI, 1.19-1.43]). CONCLUSION The high efficacy, safety, and acceptability of 400-μg sublingual misoprostol indicate that it is analogous to surgery as a first-line treatment for incomplete abortion. Misoprostol might improve post-abortion care when resources are limited and surgical treatment is unavailable.
Collapse
|
27
|
Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TNN, León W, Raghavan S, Medhat I, Huynh TKC, Barrera G, Blum J. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet 2010; 375:210-6. [PMID: 20060161 DOI: 10.1016/s0140-6736(09)61924-3] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Oxytocin, the standard of care for treatment of post-partum haemorrhage, is not available in all settings because of refrigeration requirements and the need for intravenous administration. Misoprostol, an effective uterotonic agent with several advantages for resource-poor settings, has been investigated as an alternative. This trial established whether sublingual misoprostol was similarly efficacious to intravenous oxytocin for treatment of post-partum haemorrhage in women not exposed to oxytocin during labour. METHODS In this double-blind, non-inferiority trial, 9348 women not exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at four hospitals in Ecuador, Egypt, and Vietnam (one secondary-level and three tertiary-level facilities). 978 (10%) women were diagnosed with primary post-partum haemorrhage and were randomly assigned to receive 800 microg misoprostol (n=488) or 40 IU intravenous oxytocin (n=490). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS All randomly assigned participants were analysed. Active bleeding was controlled within 20 min with study treatment alone for 440 (90%) women given misoprostol and 468 (96%) given oxytocin (relative risk [RR] 0.94, 95% CI 0.91-0.98; crude difference 5.3%, 95% CI 2.6-8.6). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1.78, 95% CI 1.40-2.26). Shivering (229 [47%] vs 82 [17%]; RR 2.80, 95% CI 2.25-3.49) and fever (217 [44%] vs 27 [6%]; 8.07, 5.52-11.8) were significantly more common with misoprostol than with oxytocin. No women had hysterectomies or died. INTERPRETATION In settings in which use of oxytocin is not feasible, misoprostol might be a suitable first-line treatment alternative for post-partum haemorrhage.
Collapse
|
28
|
Blum J, Winikoff B, Raghavan S, Dabash R, Ramadan MC, Dilbaz B, Dao B, Durocher J, Yalvac S, Diop A, Dzuba IG, Ngoc NTN. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial. Lancet 2010; 375:217-23. [PMID: 20060162 DOI: 10.1016/s0140-6736(09)61923-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin. METHODS In this double-blind, non-inferiority trial, 31 055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Vietnam (two secondary-level and three tertiary-level facilities). 809 (3%) women were diagnosed with post-partum haemorrhage and were randomly assigned to receive 800 mug misoprostol (n=407) or 40 IU intravenous oxytocin (n=402). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS All randomly assigned participants were analysed. Active bleeding was controlled within 20 min after initial treatment for 363 (89%) women given misoprostol and 360 (90%) given oxytocin (relative risk [RR] 0.99, 95% CI 0.95-1.04; crude difference 0.4%, 95% CI -3.9 to 4.6). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) women receiving misoprostol and 123 (31%) receiving oxytocin (RR 1.12, 95% CI 0.92-1.37). Shivering (152 [37%] vs 59 [15%]; RR 2.54, 95% CI 1.95-3.32) and fever (88 [22%] vs 59 [15%]; 1.47, 1.09-1.99) were significantly more common with misoprostol than with oxytocin. Six women had hysterectomies and two women died. INTERPRETATION Misoprostol is clinically equivalent to oxytocin when used to stop excessive post-partum bleeding suspected to be due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour.
Collapse
|
29
|
Akin A, Dabash R, Dilbaz B, Aktün H, Dursun P, Kiran S, Aksan G, Doğan B, Winikoff B. Increasing women's choices in medical abortion: a study of misoprostol 400 microg swallowed immediately or held sublingually following 200 mg mifepristone. EUR J CONTRACEP REPR 2009; 14:169-75. [PMID: 19565414 DOI: 10.1080/13625180902916020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess the efficacy and acceptability of two misoprostol regimens (400 microg oral or sublingual) following mifepristone for medical abortion. METHODS Women seeking abortion with gestations of 56 days or less since onset of their last menstrual period were offered medical abortion as an alternative to a surgical procedure. A total of 207 eligible and consenting women were given mifepristone (200 mg oral) and the option of taking 400 microg misoprostol either orally or sublingually two days later, with the option of home-use. Two weeks later, treatment success, satisfaction, and the frequency and acceptability of side effects were assessed. RESULTS Most women (97.6%) opted for home use of misoprostol and almost three quarters selected the oral route. Overall efficacy, acceptability of side effects and satisfaction were high in both groups. The success rate was lower after sublingual than after oral administration but not significantly so (91.3% vs. 96.3%, p = 0.23, RR: 0.93, 95% CI = 0.85-1.02). The frequency and average duration of side effects in both groups were comparable except for pain/cramps and fever/chills, which were more frequently associated with the sublingual route. CONCLUSIONS This study re-emphasises the feasibility of integrating medical abortion into health services in Turkey and the potential to increase choices for women.
Collapse
Affiliation(s)
- Ayşe Akin
- Hacettepe University School of Medicine, Ankara, Turkey
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Dilbaz B, Yalvac S, Dabash R, Dzuba I, Erkaya S, Haberal A, Kandemir O, Winikoff B. P229 The effect of active management on postpartum blood loss in a Turkish maternity hospital. Int J Gynaecol Obstet 2009. [DOI: 10.1016/s0020-7292(09)61719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
31
|
Orner P, Harries J, Cooper D, Moodley J, Hoffman M, Becker J, McGrory E, Dabash R, Bracken H. Challenges to microbicide introduction in South Africa. Soc Sci Med 2006; 63:968-78. [PMID: 16600447 DOI: 10.1016/j.socscimed.2006.02.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Indexed: 11/16/2022]
Abstract
Qualitative research was conducted in South Africa to determine perceptions about intra-vaginal microbicides in order to better understand the socioeconomic, cultural and structural contexts for the support of future introduction of this new HIV prevention method. Focus group discussions and in-depth interviews were conducted at community, health service, and policy levels of inquiry. The main study site was a black working class urban area close to Cape Town. "Desperation" in response to the HIV/AIDS epidemic, rape, sexual coercion and unplanned consensual sex emerged as major reasons to support microbicides, while concerns about the partial effectiveness of microbicide protection and its hypothetical nature elicited a more cautious approach. Other key findings included the likelihood that microbicides would be "mainstream", the possible impact on sexual practices and gender norms, issues of condom substitution/migration and potential avenues for education and distribution. We found that microbicides have the potential to meet diverse needs beyond that suggested by prior research. This included a desire for products that could protect against HIV infection following rape, sexual coercion and unplanned sex, and the finding that a wider range of people than previously suggested would potentially use microbicides. The challenge for microbicide introduction will be to develop products that can meet diverse needs not only in South Africa, but also in the broader global context.
Collapse
|
32
|
Dabash R, Vajpayee J, Jacob M, Dzuba I, Lal N, Bradley J, Prasad LB. A strategic assessment of cervical cancer prevention and treatment services in 3 districts of Uttar Pradesh, India. Reprod Health 2005; 2:11. [PMID: 16336668 PMCID: PMC1327684 DOI: 10.1186/1742-4755-2-11] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Accepted: 12/08/2005] [Indexed: 11/10/2022] Open
Abstract
Background Despite being a preventable disease, cervical cancer claims the lives of almost half a million women worldwide each year. India bears one-fifth of the global burden of the disease, with approximately 130,000 new cases a year. In an effort to assess the need and potential for improving the quality of cervical cancer prevention and treatment services in Uttar Pradesh, a strategic assessment was conducted in three of the state's districts: Agra, Lucknow, and Saharanpur. Methods Using an adaptation of stage one of the World Health Organization's Strategic Approach to Improving Reproductive Health Policies and Programmes, an assessment of the quality of cervical cancer services was carried out by a multidisciplinary team of stakeholders. The assessment included a review of the available literature, observations of services, collection of hospital statistics and the conduct of qualitative research (in-depth interviews and focus group discussions) to assess the perspectives of women, providers, policy makers and community members. Results There were gaps in provider knowledge and practices, potentially attributable to limited provider training and professional development opportunities. In the absence of a state policy on cervical cancer, screening of asymptomatic women was practically absent, except in the military sector. Cytology-based cancer screening tests (i.e. pap smears) were often used to help diagnose women with symptoms of reproductive tract infections but not routinely screen asymptomatic women. Access to appropriate treatment of precancerous lesions was limited and often inappropriately managed by hysterectomy in many urban centers. Cancer treatment facilities were well equipped but mostly inaccessible for women in need. Finally, policy makers, community members and clients were mostly unaware about cervical cancer and its preventable nature, although with information, expressed a strong interest in having services available to women in their communities. Conclusion To address gaps in services and unmet needs, state policies and integrated interventions have the potential to improve the quality of services for prevention of cervical cancer in Uttar Pradesh.
Collapse
Affiliation(s)
| | | | | | | | | | | | - LB Prasad
- Family Welfare, Uttar Pradesh, India
| |
Collapse
|
33
|
Hajri S, Blum J, Gueddana N, Saadi H, Maazoun L, Chélli H, Dabash R, Winikoff B. Expanding medical abortion in Tunisia: women's experiences from a multi-site expansion study. Contraception 2005; 70:487-91. [PMID: 15541411 DOI: 10.1016/j.contraception.2004.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 06/24/2004] [Accepted: 06/25/2004] [Indexed: 10/26/2022]
Abstract
From November 2000 to July 2001, 321 consenting women were enrolled at four sites across the country in an effort to demonstrate that mifepristone medical abortion could safely be used by providers throughout Tunisia. Women who met the study's inclusion criteria were given 200 mg oral mifepristone and offered the choice of taking 400 microg oral misoprostol 2 days later either at home or at the clinic. At follow-up, women were examined to determine completed abortion status and surveyed to gauge their satisfaction with the method. Ninety-six percent of women had a successful abortion using this method. Women expressed a strong preference for home use of misoprostol, indicating that it is more confidential (34%), easier (28%) and requires fewer clinic visits (28%). The high rate of success, demonstrated safety and acceptability of the method in new facilities and with new providers suggests that medical abortion can be safely expanded to new settings with reasonable levels of training and supervision.
Collapse
|