Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study.

BACKGROUND: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs), and explores providers' and CHWs' perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. METHODS: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. RESULTS: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. CONCLUSIONS: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women's privacy needs and address healthcare workers' concerns on managing any procedural risk.

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa.

This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.

Immediate versus delayed insertion of the copper intrauterine device after medical abortion at 17-20 gestational weeks: a randomised controlled trial.

INTRODUCTION: This trial reports on use of the copper intrauterine device (IUD) after immediate compared with delayed insertion following medical abortion at 17-20 gestational weeks (GW). METHODS: This randomised controlled trial was conducted at one tertiary hospital and five community healthcare centres in Cape Town, South Africa. Eligible consenting women were randomised to immediate (within 24 hours) or delayed (3 weeks post-abortion) insertion of the copper IUD. Follow-up was at 6 weeks, 3 months and 6 months. Main outcomes were use of the original IUD and use of any IUD, including replacement IUDs at 6 weeks post-abortion. Secondary outcomes included rates of expulsion and malposition at 6 weeks, use of any IUD at 3 and 6 months, and acceptability of the IUD. RESULTS: We recruited and randomised 114 women admitted for elective medical abortion between August 2018 and June 2019. In the immediate and delayed study arms, respectively, 45/55 (82%) and 12/57 (21%) women received the IUD as planned. By intention-to-treat, 56% in the immediate and 19% in the delayed arms were using the original IUD at 6 weeks (p<0.001), and 76% in the immediate and 40% in the delayed arms were using any IUD (p<0.001). Complete expulsion or removal occurred in 32% in the immediate and 7% in the delayed arms (p=0.044). CONCLUSIONS: Insertion of an IUD immediately after medical abortion at 17-20 GW results in increased use after 6 weeks compared with delayed insertion, however expulsion rates are higher than with interval insertion. CLINICAL TRIALS REGISTRATION: NCT03505047), Pan African Trials Registry (www.pactr.org), 201804003324963.

Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa.

OBJECTIVE: To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. METHODS: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort. RESULTS: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. CONCLUSION: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.

Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa.

OBJECTIVE: To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. DESIGN: Diagnostic accuracy study. SETTING: Ethiopia, India and South Africa. METHODS: Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS: Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION: The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.

School-based human papillomavirus vaccination: An opportunity to increase knowledge about cervical cancer and improve uptake of screening.

BACKGROUND: Poor knowledge about cervical cancer plays a role in limiting screening uptake. HPV vaccination provides an untested platform to distribute information that could possibly improve knowledge and screening coverage. OBJECTIVE: To measure changes in knowledge and screening uptake when information and screening opportunities were provided to mothers of adolescent HPV vaccine recipients. METHODS: During an HPV vaccine implementation project in the Western Cape (WC) and Gauteng Province (GP), South Africa, information about cervical cancer was provided to parents during a lecture, written information was distributed, and mothers were then invited to either screen at their clinic (WC) or use a self-screening kit (GP). A structured questionnaire was used to test cervical cancer knowledge and screening practices, comparing these before and after the project and between the two screening groups. RESULTS: Complete data for both questionnaires were available for 777 of 906 recruited women. Initial knowledge was poor, but on retesting 6 months later, knowledge about symptoms (p<0.005), screening (p<0.005) and vaccination (p<0.05) improved significantly after the information session and school-based HPV vaccination. In the second questionnaire, women reported significantly more screening and the last reported screening test was more recent. This improvement was more favourable in GP than in the WC (41% v. 26% reporting screening in the past 12 months). CONCLUSION: These results demonstrate how adolescent HPV vaccine programmes can help to control cervical cancer among mothers by offering information and screening. It is important not to lose this opportunity to educate mothers and their daughters and offer effective methods to prevent cervical cancer in both generations.