Post abortion care in Uganda : improving access and quality of care through task sharing and exploring the perspectives of young women and healthcare providers

BACKGROUND. Unsafe abortions in Uganda continue to cause significant harm to women’s health and lives and pose a heavy burden on the health system. The consistent shortage and maldistribution of healthcare providers impede women’s access to sexual and reproductive healthcare including post abortion care. Research and government reports indicate that access to post abortion care is inequitable and that the quality of care is sometimes poor. A task share between physicians and midwifes in the diagnosis and treatment of 1st trimester incomplete abortion using misoprostol, has the potential to increase women’s access to care. Improving access and quality of care further demands better appreciation of abortion decision-making and care-seeking, as well as clarity surrounding the quality of post abortion care and aspect that contribute to sub-standard care. AIM. The aim of this thesis is to identify means to improve access and quality of post abortion care in low-resource settings through task sharing and by exploring the perspectives of young women and healthcare providers in Uganda. METHODS. Study I was a multi-centre randomised controlled equivalence trial carried out in the central region of Uganda. The study aimed to investigate the safety, effectiveness and acceptability of diagnosis and treatment of 1st trimester incomplete abortion with misoprostol provided by midwives compared with physicians. Study II focused on the perspectives of young women (15–24 years) seeking post abortion care. The study explored reproductive agency in relation to unsafe abortion through individual in-depth interviews. We wanted to understand how the social environment shaped young women’s reproductive agency and actions, and under what circumstances abortions were conducted and post-abortion care was sought. Study III focused on healthcare providers’ perspectives on post abortion care. Individual in-depth interviews were conducted with midwives providing post abortion care. We specifically wanted to shed light on the quality of care, including working conditions and the role of stigma. FINDINGS. We found that diagnosis and treatment of 1st trimester incomplete abortion with misoprostol was safe, effective and acceptable when care was provided by midwives compared with physicians. Women’s acceptability was high and influenced by treatment experience and outcome (Study I). Interviews with young women revealed that reproductive agency was constrained and heavily influenced by stigma. Abortion was described as their least-wanted yet only option. At the same time, abortion was depicted as an agentive action intended to reclaim control. Maintaining secrecy was key but also incurred risk taking, and when experiencing complications, many women struggled to access care. The abortion experience seemed to shape discourse in relation to contraceptive intentions and decision-making (Study II). We found that midwives were dedicated to prevent mortality and morbidity and considered post abortion care an essential part of midwifery. However, midwives’ personal morality conflicted with their professional duty and commitment to provide post abortion care of good quality. Together with a challenging work environment, this hampered the provision of good-quality care. Finally, we found that stigma extended to both healthcare providers and women seeking care, especially to women who had induced an abortion (Study III). CONCLUSIONS Scaling up task sharing with midwives in post abortion care using misoprostol is safe, effective and highly acceptable to women and can improve access to care (Study I). Enabling young women’s reproductive agency requires addressing harmful gender norms and stigma related to pregnancy and abortion. Improving access to safe abortion and contraceptives is paramount to young women’s empowerment and their sexual and reproductive health and rights (Study II). Safeguarding equitable and good-quality post abortion care requires an enabling environment and strengthening of the midwifery role. Furthermore, abortion stigma and its implications for both healthcare providers and care-seeking women must be addressed (Study III). Findings from this thesis may be used to guide future endeavours to improve access and quality of post abortion care, and to promote and protect the sexual and reproductive health and rights of young women

The impact of third-party authorization requirements on abortion-related outcomes: a synthesis of legal and health evidence.

Objectives This review synthesizes legal and health evidence to demonstrate the health and human rights impacts of third-party authorization requirements (TPAs) on abortion seekers. Results The synthesized evidence substantiates the pre-existing position in international human rights law that requirements that abortion be authorized by third parties like parents, spouses, committees, and courts create barriers to abortion, should not be introduced at all, or should be repealed where they exist. Conclusions The review establishes that rights-based regulation of abortion should not impose TPAs in any circumstances. Instead, the provision and management of abortion should be treated in a manner cognizant with the general principles of informed consent in international human rights law, presuming capacity in all adults regardless of marital status and treatment sought, and recognizing the evolving capacity of young people in line with their internationally-protected rights

Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa – a point of (no) return

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) – target 3.7 on ensuring universal access to SRHR and target 5 on gender equality – but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyon

Evaluating the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians: study protocol for a randomized controlled equivalence trial.

BACKGROUND: A large proportion of abortion-related mortality and morbidity occurs in the second trimester of pregnancy. The Uganda Ministry of Health policy restricts management of second-trimester incomplete abortion to physicians who are few and unequally distributed, with most practicing in urban regions. Unsafe and outdated methods like sharp curettage are frequently used. Medical management of second-trimester post-abortion care by midwives offers an advantage given the difficulty in providing surgical management in low-income settings and current health worker shortages. The study aims to assess the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians. METHODS: A randomized controlled equivalence trial implemented at eight hospitals and health centers in Central Uganda will include 1192 eligible women with incomplete abortion of uterine size > 12 weeks up to 18 weeks. Each participant will be randomly assigned to undergo a clinical assessment and treatment by either a midwife (intervention arm) or a physician (control arm). Enrolled participants will receive 400 μg misoprostol administered sublingually every 3 h up to five doses within 24 h at the health facility until a complete abortion is confirmed. Women who do not achieve complete abortion within 24 h will undergo surgical uterine evacuation. Pre discharge, participants will receive contraceptive counseling and information on what to expect in terms of side effects and signs of complications, with follow-up 14 days later to assess secondary outcomes. Analyses will be by intention to treat. Background characteristics and outcomes will be presented using descriptive statistics. Differences between groups will be analyzed using risk difference (95% confidence interval) and equivalence established if this lies between the predefined range of - 5% and + 5%. Chi-square tests will be used for comparison of outcome and t tests used to compare mean values. P ≤ 0.05 will be considered statistically significant. DISCUSSION: Our study will provide evidence to inform national and international policies, standard care guidelines and training program curricula on treatment of second-trimester incomplete abortion for improved access. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03622073 . Registered on 9 August 2018

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

BACKGROUND: To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda. METHODS: Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13-18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 μg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was -5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073. FINDINGS: Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was -2·3% (95% CI -4·4 to -0·3), and within our predefined equivalence range (-5% to 5%). Two women in the midwife group received blood transfusion. INTERPRETATION: Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care. FUNDING: Swedish Research Council and THRiVE-2

Associations between the COVID-19 pandemic and women’s fertility intentions: a multi-country, cross-sectional (I-SHARE) study

Introduction The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women. Methods A multi-country, cross-sectional study based on data from 10 672 women aged 18–49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters. Results Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses. Conclusions Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium.

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks