Male circumcision uptake, postoperative complications, and satisfaction associated with mid-level providers in rural Kenya

OBJECTIVE: The purpose of this study was to assess postoperative complications and patient satisfaction associated with mid-level provision of male circumcision in rural Kenya. METHODS: A prospective cohort study was conducted among children, adolescents, and adult men undergoing male circumcision from September 1, 2008 to December 4, 2008 at Marie Stopes International Kenya mobile outreach sites located in eight districts in the Nyanza and Western Provinces, Kenya. Male circumcision procedures were performed by registered nurses, surgical technicians, or nurse aides. Postoperative follow-up visits took place on the day of the procedure and at postoperative days 3, 7, and 30, with additional visits as necessary. Data on adverse events, healing conditions, satisfaction level, and resumption of activities were assessed at each follow-up visit. RESULTS: A total of 285 individuals were screened, and 240 underwent male circumcision procedures. All procedures were performed using the guided forceps technique by mid-level providers. At the first follow-up visit (postoperative day 3), 5.8% (n = 14) individuals did not return for post-surgical assessment. Retention rates at the second (day 7) and third (day 30) follow-up visits were 91.3% (n = 219) and 84.6% (n = 203), respectively. The prevalence of complications (moderate and severe adverse events) was 1.3% (3/240). At the first and second follow-up visits, 91.7% of patients (n = 220) were capable of resuming their daily activities, and 100% by day 30. The majority of patients (>99%) were satisfied with the procedure, counseling, and information received. CONCLUSION: Male circumcisions can be delivered safely and successfully by mid-level providers in rural settings with high client satisfaction, thereby increasing access to human immunodeficiency virus prevention services in Kenya

Comparing the World Health Organization-versus China-recommended protocol for first-trimester medical abortion: a retrospective analysis

OBJECTIVE: To compare the effectiveness, in terms of complete abortion, of the World Health Organization (WHO)- and the China-recommended protocol for first-trimester medical abortion. METHODS: A retrospective analysis of clinical data from women presenting for first trimester medical abortion between January 2009 and August 2010 at reproductive health clinics in Qingdao, Xi'an, Nanjing, Nanning, and Zhengzhou was conducted. One clinic in Qingdao administered the WHO-recommended protocol (200 mg mifepristone orally followed by 0.8 mg misoprostol buccally 36-48 hours later). Four clinics in the other locations provided the China-recommended procedure (Day 1: 50 mg of mifepristone in the morning, 25 mg in the afternoon; Day 2: 50 mg of mifepristone in the morning, 25 mg in the afternoon; Day 3: 0.6 mg oral misoprostol). Data on reproductive and demographic characteristics were extracted from clinic records, and complete termination was determined on day 14 (post-mifepristone administration). RESULTS: A total of 337 women underwent early medical abortion (167 WHO- and 170 China-recommended procedures). Complete abortion was significantly higher among women who had the WHO protocol than those who received the China protocol (91.0% vs 77.7%, respectively; P < 0.001). Women using the China-recommended protocol were three times more likely to require an additional dose of misoprostol than women using the WHO protocol (21.8% vs 7.8%, respectively; P < 0.001), and had significantly more bleeding on the day of misoprostol administration (12.5 mL vs 18.5 mL; P < 0.001). CONCLUSION: This clinical audit provides preliminary evidence suggesting the WHO-recommended protocol may be more effective than the China-recommended protocol for early medical abortion. A larger scale study is necessary to compare the methods' effectiveness and acceptability

Cervical preparation for first trimester surgical abortion.

BACKGROUND: Preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy. OBJECTIVES: To determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred. SEARCH STRATEGY: We searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, we hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches. SELECTION CRITERIA: Randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review. DATA COLLECTION AND ANALYSIS: Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data. MAIN RESULTS: When compared to placebo, misoprostol (400-600 microg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F(2alpha) (2.5 mg administered intracervically) demonstrated larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion. Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.When misoprostol (600 microg oral or 800 microg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects. Compared to day-prior laminaria tents, 200 or 400 microg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E(2) andF(2alpha)) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women's satisfaction with cervical preparatory techniques. AUTHORS' CONCLUSIONS: Modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion. Mifepristone 200 mg, osmotic dilators and misoprostol, 400microg administered either vaginally or sublingually, are the most effective methods of cervical preparation

Evaluating a LARC Expansion Program in 14 Sub-Saharan African Countries: A Service Delivery Model for Meeting FP2020 Goals.

Objectives In many sub-Saharan African countries, the use of long-acting reversible contraceptives (LARCs) is low while unmet need for family planning (FP) remains high. We evaluated the effectiveness of a LARC access expansion initiative in reaching young, less educated, poor, and rural women. Methods Starting in 2008, Marie Stopes International (MSI) has implemented a cross-country expansion intervention to increase access to LARCs through static clinics, mobile outreach units, and social franchising of private sector providers. We analyzed routine service statistics for 2008-2014 and 2014 client exit interview data. Indicators of effectiveness were the number of LARCs provided and the percentages of LARC clients who had not used a modern contraceptive in the last 3 months ("adopters"); switched from a short-term contraceptive to a LARC ("switchers"); were aged <25; lived in extreme poverty; had not completed primary school; lived in rural areas; and reported satisfaction with their overall experience at the facility/site. Results Our annual LARC service distribution increased 1037 % (from 149,881 to over 1.7 million) over 2008-2014. Of 3816 LARC clients interviewed, 46 % were adopters and 46 % switchers; 37 % were aged 15-24, 42 % had not completed primary education, and 56 % lived in a rural location. Satisfaction with services received was rated 4.46 out of 5. Conclusions The effectiveness of the LARC expansion in these 14 sub-Saharan African FP programs demonstrates vast untapped potential for wider use of LARC methods, and suggests that this service delivery model is a plausible way to support FP 2020 goals of reaching those with an unmet need for FP

Mobile Technology for Improved Family Planning (MOTIF): the development of a mobile phone-based (mHealth) intervention to support post-abortion family planning (PAFP) in Cambodia.

BACKGROUND: The objective of this paper is to outline the formative research process used to develop the MOTIF mobile phone-based (mHealth) intervention to support post-abortion family planning in Cambodia. METHODS: The formative research process involved literature reviews, interviews and focus group discussions with clients, and consultation with clinicians and organisations implementing mHealth activities in Cambodia. This process led to the development of a conceptual framework and the intervention. RESULTS: Key findings from the formative research included identification of the main reasons for non-use of contraception and patterns of mobile phone use in Cambodia. We drew on components of existing interventions and behaviour change theory to develop a conceptual framework. A multi-faceted voice-based intervention was designed to address health concerns and other key determinants of contraception use. CONCLUSIONS: Formative research was essential in order to develop an appropriate mHealth intervention to support post-abortion contraception in Cambodia. Each component of the formative research contributed to the final intervention design

Safety and acceptability of tubal ligation procedures performed by trained clinical officers in rural Uganda.

OBJECTIVE: To assess safety associated with tubal ligation performed by trained clinical officers (COs) in rural Uganda. METHODS: Between March and June 2012, 518 women in 4 regions of Uganda were recruited into a prospective cohort study and followed at days 3, 7, and 45 after undergoing tubal ligation performed by a trained CO. Intraoperative and postoperative adverse events (minor, moderate, or major), and acceptability were assessed. RESULTS: Mean age was 36 years (range, 20-49 years) and mean number of living children was 6.7 (range, 0-15). The overall rate of major adverse events was 1.5%: 0.4% intraoperatively; 1.9% at day 3; and 0.2% at day 7. The majority of women who underwent tubal ligation reported a good/very good experience at the facility (range, 94%-99%) and would recommend the health services to a friend (range, 93%-98%). CONCLUSION: In the present study, task sharing of tubal ligation to trained COs in private facilities was safe. Women reported high levels of satisfaction with the procedure. Training COs could be an effective strategy for expanding family-planning services to rural Uganda

Knowledge and provision of misoprostol among pharmacy workers in Senegal: a cross sectional study.

BACKGROUND: Making misoprostol widely available for management of postpartum haemorrhage (PPH) and post abortion care (PAC) is essential for reducing maternal mortality. Private pharmacies (thereafter called "pharmacies") are integral in supplying medications to the general public in Senegal. In the case of misoprostol, pharmacies are also the main supplier to public providers and therefore have a key role in increasing its availability. This study seeks to understand knowledge and provision of misoprostol among pharmacy workers in Dakar, Senegal. METHODS: A cross-sectional survey was conducted in Dakar, Senegal. 110 pharmacy workers were interviewed face-to-face to collect information on their knowledge and practice relating to the provision of misoprostol. RESULTS: There are low levels of knowledge about misoprostol uses, registration status, treatment regimens and side effects among pharmacy workers, and corresponding low levels of training on its uses for reproductive health. Provision of misoprostol was low; of the 72% (n = 79) of pharmacy workers who had heard of the product, 35% (n = 27) reported selling it, though rarely for reproductive health indications. Almost half (49%, n = 25) of the respondents who did not sell misoprostol expressed willingness to do so. The main reasons pharmacy workers gave for not selling the product included stock outs (due to product unavailability from the supplier), perceived lack of demand and unwillingness to stock an abortifacient. CONCLUSIONS: Knowledge and availability of misoprostol in pharmacies in Senegal is low, posing potential challenges for delivery of post-abortion care and obstetric care. Training is required to address low levels of knowledge of misoprostol registration and uses among pharmacy workers. Barriers that prevent pharmacy workers from stocking misoprostol, including weaknesses in the supply chain and stigmatisation of the product must be addressed. Low reported sales for reproductive health indications also suggest limited prescribing of the product by health providers. Further research is needed to explore the reasons for this barrier to misoprostol availability

Pharmacy workers' knowledge and provision of medication for termination of pregnancy in Kenya.

OBJECTIVE: To assess pharmacy workers' knowledge and provision of abortion information and methods in Kenya. METHODS: In 2013 we interviewed 235 pharmacy workers in Nairobi, Mombasa and Kisumu about the medical abortion services they provide. We also used mystery clients, who made 401 visits to pharmacies to collect first-hand information on abortion practices. RESULTS: The majority (87.5%) of pharmacy workers had heard of misoprostol but only 39.2% had heard of mifepristone. We found that pharmacy workers had limited knowledge of correct medical abortion regimens, side effects and complications and the legal status of abortion drugs. 49.8% of pharmacy workers reported providing abortion information to clients and 4.3% reported providing abortion methods. 75.2% of pharmacies referred mystery clients to another provider, though 64.2% of pharmacies advised mystery clients to continue with their pregnancy. Pharmacy workers reported that they were experiencing demand for abortion services from clients. CONCLUSIONS: Pharmacy workers are important providers of information and referrals for women seeking abortion, however their medical abortion knowledge is limited. Training pharmacy workers on medical abortion may improve the quality of information provided and access to safe abortion

MObile Technology for Improved Family Planning Services (MOTIF): study protocol for a randomised controlled trial.

BACKGROUND: Providing women with contraceptive methods following abortion is important to reduce repeat abortion rates, yet evidence for effective post-abortion family planning interventions are limited. This protocol outlines the evaluation of a mobile phone-based intervention using voice messages to support post-abortion family planning in Cambodia. METHODS/DESIGN: A single blind randomised controlled trial of 500 participants. Clients aged 18 or over, attending for abortion at four Marie Stopes International clinics in Cambodia, owning a mobile phone and not wishing to have a child at the current time are randomised to the mobile phone-based intervention or control (standard care) with a 1:1 allocation ratio.The intervention comprises a series of six automated voice messages to remind clients about available family planning methods and provide a conduit for additional support. Clients can respond to message prompts to request a phone call from a counsellor, or alternatively to state they have no problems. Clients requesting to talk to a counsellor, or who do not respond to the message prompts, receive a call from a Marie Stopes International Cambodia counsellor who provides individualised advice and support regarding family planning. The duration of the intervention is 3 months. The control group receive existing standard of care without the additional mobile phone-based support.We hypothesise that the intervention will remind clients about contraceptive methods available, identify problems with side effects early and provide support, and therefore increase use of post-abortion family planning, while reducing discontinuation and unsafe method switching.Participants are assessed at baseline and at 4 months. The primary outcome measure is use of an effective modern contraceptive method at 4 months post abortion. Secondary outcome measures include contraception use, pregnancy and repeat abortion over the 4-month post-abortion period.Risk ratios will be used as the measure of effect of the intervention on the outcomes, and these will be estimated with 95% confidence intervals. All analyses will be based on the 'intention to treat' principle. DISCUSSION: This study will provide evidence on the effectiveness of a mobile phone-based intervention using voice messages to support contraception use in a population with limited literacy. Findings could be generalisable to similar populations in different settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01823861

Women's perspectives on termination service delivery in Vietnam: a cross-sectional survey in three provinces.

OBJECTIVE: To explore the perspectives of abortion service users regarding termination methods and abortion service delivery in Vietnam. MATERIALS AND METHODS: Structured exit interviews were conducted between August and November 2011 with women who underwent termination of pregnancy at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City in Vietnam. All women presenting for termination during the study period were recruited to participate in the study. Following their abortion, women were asked about their perspectives on abortion service delivery and attributes of medical abortion (MA) versus manual vacuum aspiration (MVA). Multiple logistic regression was used to assess the association between current method uptake and each attribute. RESULTS: A total of 1,233 women were included in the survey: 541 (43.9%) from Hanoi, 163 (13.2%) from Khanh Hoa, and 529 (42.9%) from Ho Chi Minh: 23.1% underwent MA; 78.9% reported that women should be given a choice between MA and MVA; and 77.6% thought that abortion services were accessible. Among the 48% who responded, 30.1% thought that MA should be made available at primary/secondary health care facilities. Among women who had previously undergone both methods, women who reported that MA "feels more natural" (like a menstrual regulation/period) were more likely to choose MA for their current abortion (odds ratio 2.15, 95% confidence interval 1.26-3.69). CONCLUSION: MA uptake is significantly lower than MVA uptake. Further insights to women's perceptions of MA in Vietnam could help improve abortion service delivery in the country