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1.
BMJ Glob Health ; 6(2)2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33547174

RESUMO

INTRODUCTION: With a view to inform policy for improved postabortion care, we describe abortion-related near-miss and mortality by sociodemographic risk factors and management options by pregnancy trimester in Uganda. METHODS: This secondary data analysis used an adapted WHO near-miss methodology to collect cross-sectional maternal near-miss and abortion complications data at 43 health facilities in Central and Eastern Uganda in 2016-2017. We computed abortion severe morbidity, near-miss and mortality ratios per 100 000 live births, and described the proportion of cases that worsened to an abortion near-miss or death, stratified by geographical region and trimester. We tested for association between independent variables and abortion near-miss, and obtained prevalence ratios for association between second trimester near-miss and independent demographic and management indicators. We assessed health facility readiness for postabortion care provision in Central and Eastern regions. RESULTS: Of 3315 recorded severe abortion morbidity cases, 1507 were near-misses. Severe abortion morbidity, near-miss and mortality ratios were 2063, 938 and 23 per 100 000 live births, respectively. Abortion-related mortality ratios were 11 and 57 per 100 000 in Central and Eastern regions, respectively. Abortion near-miss cases were significantly associated with referral (p<0.001). Second trimester had greater abortion mortality than first trimester. Eastern region had greater abortion-related morbidity and mortality than Central region with facilities in the former characterised by inferior readiness to provide postabortion care. CONCLUSIONS: Uganda has a major abortion near-miss morbidity and mortality; with mortality higher in the second trimester. Life-saving commodities are lacking especially in Eastern region compromising facility readiness for postabortion care provision.

2.
Artigo em Inglês | MEDLINE | ID: mdl-32981091

RESUMO

OBJECTIVE: To assess the effect of Helping Mothers Survive Bleeding after Birth training on postpartum hemorrhage (PPH) near miss and case fatality rates in Uganda. METHODS: Training was evaluated using a cluster-randomized design between June 2016 and September 2017 in 18 typical rural districts (clusters) in Eastern and Central Uganda of which nine districts were randomly assigned to the intervention. The main outcome was PPH near miss defined using the World Health Organization's disease and management-based approach. Interrupted time series analysis was performed to estimate the difference in the change of outcomes. RESULTS: Outcomes of 58 000 and 95 455 deliveries during the 6-month baseline and 10-month endline periods, respectively, were included. A reduction of PPH near misses was observed in the intervention compared to the comparison districts (difference-in-difference of slopes 4.19, 95% CI, -7.64 to -0.74); P<0.05). There was an increase in overall reported near miss cases (difference-in-difference 1.24, 95% CI, 0.37-2.10; P<0.001) and an increase in PPH case fatality rate (difference-in-difference 2.13, 95% CI, 0.14-4.12; P<0.05). CONCLUSION: This pragmatic cluster-randomized trial conducted in typical rural districts of Uganda indicated a reduction of severe PPH cases while case fatality did not improve, suggesting that this basic training needs to be complemented by additional measures for sustained mortality reduction. TRIAL REGISTRATION: PACTR201604001582128.

3.
Int J Gynaecol Obstet ; 147(3): 389-396, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31539164

RESUMO

OBJECTIVE: To assess the consistency of maternal near-miss incidence and mortality index between two definitions across 104 facilities in Tanzania and Uganda. METHODS: Based on WHO guidance, cross-sectional near-miss data were collected in Tanzania (July 2015 to October 2016) and Uganda (June 2016 to September 2017). Prepartum hemorrhage and abortion were included as additional screening events and the number of blood units transfused was recorded. Near-miss incidence and mortality index were determined by using two near-miss definitions: the WHO standard definition, and a modified definition including women receiving at least 1 unit of blood. A sensitivity analysis excluded the additional screening events. RESULTS: Near-miss incidence differed between Tanzania and Uganda (1.79 and 4.00, respectively, per 100 deliveries) when estimated by the standard definition, but was similar (5.24 and 4.94, respectively) by the modified definition. The mortality index was higher in Tanzania than in Uganda when estimated by the standard definition (8.56% vs 3.54%), but was similar by the modified definition (3.10% vs 2.89%). CONCLUSION: The modified definition provided a more consistent estimate of near-miss incidence and mortality index. Lowering the threshold for units of blood transfusion might improve comparability between settings, but more research is needed.


Assuntos
Near Miss/estatística & dados numéricos , Complicações do Trabalho de Parto/epidemiologia , Complicações na Gravidez/epidemiologia , Adulto , Estudos Transversais , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Incidência , Mortalidade Materna , Pobreza , Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Tanzânia/epidemiologia , Uganda/epidemiologia
4.
Trials ; 20(1): 376, 2019 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-31227019

RESUMO

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.


Assuntos
Aborto Incompleto/tratamento farmacológico , Tocologia , Misoprostol/uso terapêutico , Médicos , Feminino , Humanos , Misoprostol/efeitos adversos , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Segundo Trimestre da Gravidez , Projetos de Pesquisa
5.
Int J Gynaecol Obstet ; 144(1): 37-48, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30289170

RESUMO

OBJECTIVE: To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors. METHODS: The present study was an analysis of cross-sectional patient-record and facility-file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level-4 health centers, and five level-3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non-near-miss, and intrapartum near-miss) to calculate stillbirth rates and adjusted prevalence ratios. RESULTS: Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near-miss was associated with a 3.73- and 4.55-fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near-miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non-near-miss adverse events. CONCLUSION: Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non-near-miss complications, identifying the opportunity to prevent deterioration by timely actions.


Assuntos
Complicações na Gravidez , Natimorto/epidemiologia , Adulto , Cesárea/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Near Miss/estatística & dados numéricos , Gravidez , Prevalência , Fatores de Risco , Tanzânia/epidemiologia , Uganda/epidemiologia , Adulto Jovem
6.
Trials ; 18(1): 307, 2017 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-28683806

RESUMO

BACKGROUND: Postpartum haemorrhage complicates approximately 10% of all deliveries and contributes to at least a quarter of all maternal deaths worldwide. The competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training was developed to support evidence-based management of postpartum haemorrhage. This one-day training includes low-cost MamaNatalie® birthing simulators and addresses both prevention and first-line treatment of haemorrhage. While evidence is accumulating that the training improves health provider's knowledge, skills and confidence, evidence is missing as to whether this translates into improved practices and reduced maternal morbidity and mortality. This cluster-randomised trial aims to assess whether this training package - involving a one-day competency-based HMS BAB in-facility training provided by certified trainers followed by 8 weeks of in-service peer-based practice - has an effect on the occurrence of haemorrhage-related morbidity and mortality. METHODS/DESIGN: In Tanzania and Uganda we randomise 20 and 18 districts (clusters) respectively, with half receiving the training intervention. We use unblinded matched-pair randomisation to balance district health system characteristics and the main outcome, which is in-facility severe morbidity due to haemorrhage defined by the World Health Organizationation-promoted disease and management-based near-miss criteria. Data are collected continuously in the intervention and comparison districts throughout the 6-month baseline and the 9-month intervention phase, which commences after the training intervention. Trained facility midwives or clinicians review severe maternal complications to identify near misses on a daily basis. They abstract the case information from case notes and enter it onto programmed tablets where it is uploaded. Intention-to-treat analysis will be used, taking the matched design into consideration using paired t test statistics to compare the outcomes between the intervention and comparison districts. We also assess the impact pathway from the effects of the training on the health provider's skills, care and interventions and health system readiness. DISCUSSION: This trial aims to generate evidence on the effect and limitations of this well-designed training package supported by birthing simulations. While the lack of blinding of participants and data collectors provides an inevitable limitation of this trial, the additional evaluation along the pathway of implementation will provide solid evidence on the effects of this HMS BAB training package. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR201604001582128 . Registered on 12 April 2016.


Assuntos
Pessoal de Saúde/educação , Capacitação em Serviço/métodos , Serviços de Saúde Materna , Obstetrícia/educação , Parto , Equipe de Assistência ao Paciente , Hemorragia Pós-Parto/terapia , Atitude do Pessoal de Saúde , Competência Clínica , Protocolos Clínicos , Currículo , Países em Desenvolvimento , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Análise de Intenção de Tratamento , Mortalidade Materna , Tocologia/educação , Near Miss , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/mortalidade , Gravidez , Projetos de Pesquisa , Fatores de Risco , Tanzânia , Fatores de Tempo , Resultado do Tratamento , Uganda
8.
PLoS One ; 11(2): e0149172, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26872219

RESUMO

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.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Incompleto/tratamento farmacológico , Misoprostol/uso terapêutico , Abortivos não Esteroides/efeitos adversos , Aborto Incompleto/epidemiologia , Adulto , Feminino , Humanos , Tocologia , Misoprostol/efeitos adversos , Uganda/epidemiologia
9.
Lancet ; 385(9985): 2392-8, 2015 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-25817472

RESUMO

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.


Assuntos
Abortivos não Esteroides/uso terapêutico , Aborto Incompleto/tratamento farmacológico , Tocologia/estatística & dados numéricos , Misoprostol/uso terapêutico , Médicos/estatística & dados numéricos , Aborto Incompleto/diagnóstico , Adolescente , Adulto , Países em Desenvolvimento , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Primeiro Trimestre da Gravidez , Uganda , Curetagem a Vácuo , Adulto Jovem
10.
Int J Gynaecol Obstet ; 115(3): 282-4, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21937039

RESUMO

OBJECTIVE: To determine the prevalence of and factors associated with urologic complications among women with advanced cervical cancer before treatment in Uganda. METHODS: In total, 283 women with histologically confirmed stage IIB-IVB cervical cancer who were admitted to Mulago Hospital over a 6-month period were studied. Abdominopelvic scan was carried out to check for hydronephrosis and hydroureter and to measure the tumor volume. Serum creatinine and urea levels were measured, and the presence of anuria and vesicovaginal fistula (VVF) was ascertained from self-reporting and clinical records. RESULTS: Urologic complications were present in 138 (48.8%) women. Hydronephrosis, VVF, hydroureter, and anuria were present in 112 (39.6%), 21 (7.4%), 11 (3.9%), and 9 (3.2%) women, respectively; serum creatinine and urea levels were elevated in 48 (17.0%) women. Stage of disease was significantly associated with urologic complications: stage IIIB odds ratio (OR) 3.36 (95% confidence interval [CI], 1.57-7.20); stage IVA OR 17.10 (95% CI, 6.07-48.16); P<0.001. CONCLUSION: There is a high prevalence of urologic complications among women with advanced cervical cancer; these complications are significantly associated with the stage of cervical cancer.


Assuntos
Anuria/etiologia , Hidronefrose/etiologia , Neoplasias do Colo do Útero/complicações , Fístula Vesicovaginal/etiologia , Adulto , Anuria/epidemiologia , Creatinina/sangue , Feminino , Humanos , Hidronefrose/epidemiologia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prevalência , Uganda , Ureia/sangue , Doenças Ureterais/epidemiologia , Doenças Ureterais/etiologia , Neoplasias do Colo do Útero/patologia , Fístula Vesicovaginal/epidemiologia
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