Contraceptive uptake in post abortion care-Secondary outcomes from a randomised controlled trial, Kisumu, Kenya.

AIM: The aim was to explore contraceptive uptake, associated factors and satisfaction among post abortion-care (PAC) seeking women in Kenya. Due to unsafe abortions, almost 120 000 Kenyan women received PAC in 2012, and of these women, 70% did not use contraception before pregnancy. METHODS: This study was nested in a larger randomised controlled trial, where 859 women sought PAC at two public hospitals in Kisumu, in June 2013-May 2016. The women were randomly assigned to a midwife or a physician for PAC, including contraceptive counselling, and followed up at 7-10 days and three months. Associated factors for contraceptive uptake were analysed with binary logistic regression, and contraceptive method choice, adherence and satisfaction level were examined by descriptive statistics, using IBM SPSS Statistics for Windows, Version 22.0. RESULTS: Out of the 810 PAC-seeking women, 76% (n = 609) accepted the use of contraception. Age groups of 21-25 (OR: 2.35; p < 0.029) and 26-30 (OR: 2.22; p < 0.038), and previous experience of 1-2 gravidities (OR 1.939; p = 0.018) were independent factors associated with the up-take. Methods used: injections 39% (n = 236); pills 27% (n = 166); condoms 25% (n = 151); implant 7% (n = 45) and intrauterine device (IUD) 1% (n = 8). At 3-month follow-up of the women (470/609; 77%), 354 (75%) women still used contraception, and most (n = 332; 94%) were satisfied with the method. Reasons for discontinuation were side-effects (n = 44; 39%), partner refusal (n = 27; 24%), planned pregnancy (n = 27; 24%) and lack of resupplies (n = 15; 13%). CONCLUSIONS: PAC-seeking women seem highly motivated to use contraceptives, yet a quarter decline the use, and at 3-month follow-up a further quarter among the users had discontinued. Implant, IUD and permanent method are rarely used. Strategies to improve contraceptive counselling, particularly to adolescent girls, and to increase access to a wide range of methods, as well as provider training and supervision may help to improve contraceptive acceptance and compliance among PAC-seeking women in Kisumu, Kenya.

Post-abortion care with misoprostol - equally effective, safe and accepted when administered by midwives compared to physicians: a randomised controlled equivalence trial in a low-resource setting in Kenya.

OBJECTIVE: To assess the effectiveness of midwives administering misoprostol to women with incomplete abortion seeking post-abortion care (PAC), compared with physicians. DESIGN: A multicentre randomised controlled equivalence trial. The study was not masked. SETTINGS: Gynaecological departments in two hospitals in a low-resource setting, Kenya. POPULATION: Women (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis. INTERVENTIONS: 600 µg misoprostol orally, and contraceptive counselling by a physician or midwife. MAIN OUTCOME MEASURES: Complete abortion not needing surgical intervention within 7-10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was -4% to 4%. Secondary outcomes were analysed descriptively. RESULTS: The proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (-4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7-10 days occurred in 76% (613/810). No serious adverse events were recorded. CONCLUSIONS: Treatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception. TRIAL REGISTRATION NUMBER: NCT01865136; Results.

Women's Acceptability of Misoprostol Treatment for Incomplete Abortion by Midwives and Physicians - Secondary Outcome Analysis from a Randomized Controlled Equivalence Trial at District Level in Uganda.

OBJECTIVE: This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians. METHODS: This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14-28 days following treatment. Analysis of women's overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024. RESULTS: From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded. CONCLUSIONS: Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women. TRIAL REGISTRATION: ClinicalTrials.gov NCT01844024.

Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial.

BACKGROUND: Misoprostol is established for the treatment of incomplete abortion but has not been systematically assessed when provided by midwives at district level in a low-resource setting. We investigated the effectiveness and safety of midwives diagnosing and treating incomplete abortion with misoprostol, compared with physicians. METHODS: We did a multicentre randomised controlled equivalence trial at district level at six facilities in Uganda. Eligibility criteria were women with signs of incomplete abortion. We randomly allocated women with first-trimester incomplete abortion to clinical assessment and treatment with misoprostol either by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and was stratified for study site. Primary outcome was complete abortion not needing surgical intervention within 14-28 days after initial treatment. The study was not masked. Analysis of the primary outcome was done on the per-protocol population with a generalised linear-mixed effects model. The predefined equivalence range was -4% to 4%. The trial was registered at ClinicalTrials.gov, number NCT01844024. FINDINGS: From April 30, 2013, to July 21, 2014, 1108 women were assessed for eligibility. 1010 women were randomly assigned to each group (506 to midwife group and 504 to physician group). 955 women (472 in the midwife group and 483 in the physician group) were included in the per-protocol analysis. 452 (95·8%) of women in the midwife group had complete abortion and 467 (96·7%) in the physician group. The model-based risk difference for midwife versus physician group was -0·8% (95% CI -2·9 to 1·4), falling within the predefined equivalence range (-4% to 4%). The overall proportion of women with incomplete abortion was 3·8% (36/955), similarly distributed between the two groups (4·2% [20/472] in the midwife group, 3·3% [16/483] in the physician group). No serious adverse events were recorded. INTERPRETATION: Diagnosis and treatment of incomplete abortion with misoprostol by midwives is equally safe and effective as when provided by physicians, in a low-resource setting. Scaling up midwives' involvement in treatment of incomplete abortion with misoprostol at district level would increase access to safe post-abortion care. FUNDING: The Swedish Research Council, Karolinska Institutet, and Dalarna University.

Quality of STIs and HIV/AIDS care as perceived by biomedical and traditional health care providers in Zambia: are there common grounds for collaboration?

OBJECTIVE: To explore biomedical and traditional health care providers' (BHPs and THPs, respectively) perceptions of good quality of care and opinions on weaknesses in the services they provide to patients with STIs and HIV/AIDS. METHODS: Using data from a cross-sectional survey, we post-coded two open-ended questions related to THPs' and BHPs' perceptions on good quality of care and on provided care. The post-coding was done following Donabedian's framework of assessment of quality of care, and allowed transformation of qualitative data into quantitative. The analysis is based on comparison of frequencies, proportions and subsequent chi-square tests and odds ratios. SETTING: Ndola and Kabwe, Zambia Main measures: Proportions of responses from 152 BHPs and 144 THPs. RESULTS: Substantial proportions of providers from both sectors perceived drugs availability (63% of BHPs and 70% of THPs) and welcoming attitude (73% of BHPs and 64% of THPs) as important components of good quality care. BHPs were more likely than THPs to mention proper examination, medical management (provider's technical ability) and explanation of causes and prognosis of the disease as important. More THPs than BHPs cited short waiting time and cost of care. A majority of BHPs (87%) and of THPs (80%) reported deficiencies in their STIs and HIV/AIDS-related services. Both groups regarded training of providers and nutritional support and health education to patients as lacking. None of the THPs alluded to voluntary counselling and testing (VCT) or supportive/home-based care as aspects needing improvement. CONCLUSION: Drugs availability and welcoming attitude were two aspects of quality highly valued by THPs and BHPs. Future collaborative interventions need to respond to aspects of joint concern including training of providers, nutritional support and health education to patients. Further, there is an imperative of expanding and adapting VCT, home-based care and palliative care to THPs for better care of STIs and HIV/AIDS.

Can biomedical and traditional health care providers work together? Zambian practitioners' experiences and attitudes towards collaboration in relation to STIs and HIV/AIDS care: a cross-sectional study.

BACKGROUND: The World Health Organization's World health report 2006: Working together for health underscores the importance of human resources for health. The shortage of trained health professionals is among the main obstacles to strengthening low-income countries' health systems and to scaling up HIV/AIDS control efforts. Traditional health practitioners are increasingly depicted as key resources to HIV/AIDS prevention and care. An appropriate and effective response to the HIV/AIDS crisis requires reconsideration of the collaboration between traditional and biomedical health providers (THPs and BHPs). The aim of this paper is to explore biomedical and traditional health practitioners' experiences of and attitudes towards collaboration and to identify obstacles and potential opportunities for them to collaborate regarding care for patients with sexually transmitted infections (STIs) and HIV/AIDS. METHODS: We conducted a cross-sectional study in two Zambian urban sites, using structured questionnaires. We interviewed 152 biomedical health practitioners (BHPs) and 144 traditional health practitioners (THPs) who reported attending to patients with STIs and HIV/AIDS. RESULTS: The study showed a very low level of experience of collaboration, predominated by BHPs training THPs (mostly traditional birth attendants) on issues of safe delivery. Intersectoral contacts addressing STIs and HIV/AIDS care issues were less common. However, both groups of providers overwhelmingly acknowledged the potential role of THPs in the fight against HIV/AIDS. Obstacles to collaboration were identified at the policy level in terms of legislation and logistics. Lack of trust in THPs by individual BHPs was also found to inhibit collaboration. Nevertheless, as many as 40% of BHPs expressed an interest in working more closely with THPs. CONCLUSION: There is indication that practitioners from both sectors seem willing to strengthen collaboration with each other. However, there are missed opportunities. The lack of collaborative framework integrating maternal health with STIs and HIV/AIDS care is at odds with the needed comprehensive approach to HIV/AIDS control. Also, considering the current human resources crisis in Zambia, substantial policy commitment is called for to address the legislative obstacles and the stigma reported by THPs and to provide an adequate distribution of roles between all partners, including traditional health practitioners, in the struggle against HIV/AIDS.

Communities' views on prerequisites for collaboration between modern and traditional health sectors in relation to STI/HIV/AIDS care in Zambia.

Traditional, complementary and alternative medicine (TM/CAM) is globally increasing in popularity. The World Health Organization (WHO) has advocated for the integration of TM/CAM in national public health policies to enhance health care resources. Interest in collaboration between traditional and biomedical health sectors has been renewed in attempts to strengthen control of the AIDS epidemic. However, studies exploring communities' views on the prerequisites for such collaboration are inexistent. We conducted 21 focus group discussions with community members in two Zambian urban centres (Ndola and Kabwe) to explore their perspectives on preconditions for useful collaboration between traditional and modern health workers in the management of STIs and HIV/AIDS. This study shows that laypersons' perspectives can be rich and inform complex policy issues. Five categories indicating key areas of actions were identified, including protection of traditional medicine and of compensation of healers, education of both groups of providers and adequate community involvement. The respect for some degree of secrecy in traditional medicine was also called for. As part of efforts to strengthen available resources for better care of STI/HIV/AIDS, this study provides policymakers, researchers and practitioners with an outline of fundamentals in terms of needed crucial changes at health policy level, among providers and in the community for sustainable collaboration between modern and traditional health practitioners.

Experiences of pregnant adolescents--voices from Wakiso district, Uganda.

BACKGROUND: In Uganda, morbidity and mortality among adolescent mothers and their children are high. Social factors behind this problem need to be better understood. OBJECTIVE: To explore problems that pregnant adolescents face in order to design appropriate policies and interventions. METHODS: This was a descriptive study that utilized qualitative methods for data collection. The study population comprised of pregnant adolescents, adolescent mothers, opinion leaders, In-charge of health unit, and Traditional Birth Attendants (TBAs) in Wakiso district, Uganda. Six Focus Group Discussions (FGDs) with adolescent mothers and pregnant adolescents, and six key informant interviews were conducted with leaders in-charge of health units and TBAs. A moderator and a note taker facilitated the FGDs, which were tape recorded with consent from participants. Qualitative content analysis was done. RESULTS: Discussions revealed that pregnant adolescents faced domestic physical violence. Furthermore, they were psychologically violated by parents and partners, and the community within which they lived. Pregnant adolescents were treated inhumanely and overworked with household chores and had inadequate food to eat. Adolescents experienced stigma and as a result some had carried out unsafe abortions. Key informant interviews and FGDs revealed that health workers were rude and unsympathetic to pregnant adolescents. This significantly contributed to delayed health care seeking when adolescents were ill. CONCLUSION: Pregnant adolescents lack basic needs like shelter, food and security. They also face relational problems with families, partners and the community. There is, therefore, a need to sensitize the community and school personnel about adolescent reproductive health issues. In addition, adolescent friendly services need to be established/strengthened. Continuous in-service training for health workers with emphasis on counseling skills for young people is urgently needed.

Beliefs and reality: detection and prevention of high alcohol consumption in Swedish antenatal clinics.

BACKGROUND: Public antenatal care (ANC) clinics in Sweden contribute to low prenatal mortality and morbidity, through early detection of somatic risk factors, and referral to appropriate specialized care. Available statistics indicate, however, that this system is ineffective in dealing with psychosocial health problems, such as hazardous drug and alcohol use. Factors underlying this failure have not been explored. METHODS: An anonymous survey was carried out among all 207 ANC midwives in Stockholm County to establish their level of training within this problem area, clinical experience, theoretical clinical strategies, and actual clinical actions. FINDINGS: Responses indicate that ANC midwives: 1. are well aware of the health hazards of drug and alcohol use during pregnancy; 2. confirm having met and cared for subjects with hazardous substance use; 3. are familiar with specialized care resources available for this patient category; 4. make adequate choices regarding clinical action, i.e. problem identification and referral to specialized care, in hypothetical situations of encountering this patient category; 5. report consistent failure to actually exercise these choices in real clinical situations. CONCLUSIONS: A structured, clinically acceptable methodology needs to be developed in order for ANC clinics to fulfill their mission in the area of hazardous substance use in pregnant women.