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1.
BMJ Glob Health ; 6(2)2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33558339

RESUMO

As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to fully integrate inter alia human rights. This paper describes an innovative methodological approach taken by the authors to inform law and policy recommendations for the forthcoming third edition of the Safe Abortion: Technical and Policy Guidance for Health Systems. The methodology described here effectively integrates human rights protection and enjoyment as part of health outcomes and analysis, ensuring that subsequent recommendations are consistent with international human rights standards. This will allow guideline users to make informed decisions on interventions, including legal and policy reform, to fulfil relevant human rights including the right to health.

2.
Int J Gynaecol Obstet ; 150 Suppl 1: 34-42, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33219992

RESUMO

We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.

3.
Reprod Health ; 17(1): 67, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434523

RESUMO

BACKGROUND: Adolescent pregnancies are persistently high among refugees. The pregnancies have been attributed to low contraceptive use in this population. The aim of this study was to determine the prevalence and factors associated with modern contraceptive use among female refugee adolescents in northern Uganda. METHODS: This was a cross sectional study using both descriptive and analytical techniques. The study was carried out in Palabek refugee settlement in Northern Uganda from May to July 2019. A total of 839 refugee adolescents who were sexually active or in-union were consecutively enrolled. Interviewer administered questionnaires were used for data collection. RESULTS: Modern contraceptive prevalence was 8.7% (95% CI: 7.0 to 10.8). The injectable was the most commonly used modern contraceptive method [42.5% (95% CI: 31.5 to 54.3)], and most of the participants had used the contraceptives for 6 months or less (59.7%). Reasons for not using modern contraceptives included fear of side effects (39.3%), partner prohibition (16.4%), and the desire to become pregnant (7.0%). Participants who were married (OR = 0.11, 95% CI: 0.04 to 0.35, p < 0.001), cohabiting (OR = 0.43, 95% CI: 0.20 to 0.93, p = 0.032) or having an older partner (OR = 0.93, 95% CI: 0.86 to 0.99, p = 0.046) were less likely to use modern contraceptives. CONCLUSION: Modern contraceptive use among female refugee adolescents was very low, and few reported a desire to become pregnant, leaving them vulnerable to unplanned pregnancies. Least likely to use modern contraceptives were participants who were married/cohabiting and those having older partners implying a gender power imbalance in fertility decision making. There is an urgent need for innovations to address the gender and power imbalances within relationships, which could shape fertility decision-making and increase modern contraceptive use among refugee adolescents.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31383555

RESUMO

We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.


Assuntos
Abortivos , Aborto Induzido , Acesso aos Serviços de Saúde , Misoprostol , Telemedicina , Abortivos/administração & dosagem , Abortivos/provisão & distribução , Feminino , Humanos , Internet , Mortalidade Materna , Mifepristona/administração & dosagem , Mifepristona/provisão & distribução , Misoprostol/administração & dosagem , Misoprostol/provisão & distribução , Gravidez , Qualidade da Assistência à Saúde
5.
Int J Gynaecol Obstet ; 147(3): 301-312, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31493314

RESUMO

BACKGROUND: Optimal dose, interval, and administration route of misoprostol with added benefit of mifepristone for management of second trimester intrauterine fetal death (IUFD) are not established. OBJECTIVES: To assess effectiveness, safety, and acceptability of medical management of second trimester IUFD. SEARCH STRATEGY: Research databases from January 2006 to October 2018. SELECTION CRITERIA: Randomized controlled trials with IUFD cases at 14-28 weeks of gestation. DATA COLLECTION AND ANALYSIS: We screened and extracted data, assessed risk of bias, conducted analyses, and assessed overall certainty of the evidence. MAIN RESULTS: Sixteen trials from 1695 citations. When misoprostol is used alone, 400 µg is more effective than 200 µg (RR 0.78; 95% CI, 0.66-0.92, moderate certainty evidence); the sublingual route is more effective than the oral route (RR 0.88; 95% CI, 0.70-1.11, low certainty evidence). There may be little to no difference between the sublingual and vaginal route (RR 0.93; 95% CI, 0.85-1.03, low certainty evidence). Certainty of evidence related to mifepristone-misoprostol regimens and safety and acceptability is very low. CONCLUSIONS: Misoprostol 400 µg every 4 hours, sublingually or vaginally, may be effective. We cannot draw conclusions about safety and acceptability, or about the added benefits of mifepristone.


Assuntos
Abortivos não Esteroides/administração & dosagem , Abortivos Esteroides/administração & dosagem , Aborto Induzido/métodos , Morte Fetal , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Aborto Induzido/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Humanos , Gravidez , Segundo Trimestre da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
6.
Midwifery ; 77: 71-77, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31255911

RESUMO

OBJECTIVE: We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care. DESIGN: This was a qualitative study using individual in-depth interviews and an inductive thematic analysis. SETTING AND PARTICIPANTS: Interviews were conducted with 22 midwives (the 'informants') providing PAC in a public hospital in Kampala, Uganda. The narratives were based on experiences in current and previous workplaces, in rural and urban settings. FINDINGS: The findings comprise one main theme - morality versus duty to provide quality post-abortion care - and three sub-themes. Our findings confirm that the midwives were committed to saving women's lives but had conflicting personal morality in relation to abortion and sense of professional duty, which seemed to influence their quality of care. Midwives were proud to provide PAC, which was described as a natural part of midwifery. However, structural challenges, such as lack of supplies and equipment and high patient loads, hampered provision of good quality care and left informants feeling frustrated. Although abortion was often implied to be immoral, the experience of PAC provision appeared to shape views on legality, leading to an ambiguous, yet more liberal, stance. Abortion stigma was reported to exist within communities and the health workforce, extending to both providers and care-seeking women. Informants had witnessed mistreatment of women seeking care due to abortion complications, through deliberate care delays and denial of pain medication. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives in PAC were dedicated to saving women's lives; however, conflicting morality and duty and poor working conditions seemed to impede good-quality care. Enabling midwives to provide good quality care includes increasing the patient-midwife ratio and ensuring essential resources are available. Additionally, efforts that de-stigmatise abortion and promote accountability are needed. Implementation of policies on respectful post-abortion care could aid in ensuring all women are treated with respect.


Assuntos
Aborto Induzido/enfermagem , Obrigações Morais , Princípios Morais , Enfermeiras Obstétricas/psicologia , Cuidado Pós-Natal/métodos , Adulto , Atitude do Pessoal de Saúde , Feminino , Humanos , Entrevistas como Assunto/métodos , Pessoa de Meia-Idade , Enfermeiras Obstétricas/estatística & dados numéricos , Cuidado Pós-Natal/psicologia , Cuidado Pós-Natal/estatística & dados numéricos , Pesquisa Qualitativa , Uganda
7.
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
9.
Cult Health Sex ; 19(11): 1286-1300, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28398161

RESUMO

Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one's body and future. Women's experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.


Assuntos
Aborto Criminoso/psicologia , Saúde Reprodutiva/normas , Comportamento Sexual , Normas Sociais , Adolescente , Feminino , Humanos , Entrevistas como Assunto , Mortalidade Materna , Gravidez , Estigma Social , Uganda , Adulto Jovem
11.
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
12.
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
13.
Sex Reprod Healthc ; 5(3): 137-41, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25200975

RESUMO

OBJECTIVE: Female sex workers (FSWs) are at risk of unintended pregnancies and induced abortions (IAs). This study aimed to describe attitudes towards and experiences of IA among FSWs in Laos. METHODS: 258 FSWs were interviewed in Kaysone Phomvihan, Laos. Descriptive statistics and logistic regression were used to analyse the data. RESULTS: Overall, 24% of the respondents reported experience of IA. Fifteen percent reported experience of unintended pregnancy after entering sex work, whereof all had ended in IA. Thirty-six percent had self-induced the last IA and 64% were carried out in private clinics. The main reasons for having IAs were paternity denial and lack of financial and social support. A majority agreed or strongly agreed that IA should not be legal in Laos and that women who undergo IA are immoral, but also that IA is the only option a FSW has when experiencing an unintended pregnancy. A positive attitude towards IA was associated with longer duration of sex work and being unmarried. CONCLUSION: IAs were common. Respondents' attitudes and practices reflected limited options when experiencing an unintended pregnancy, and were influenced by negative social perceptions. Interventions targeting FSWs should raise awareness of IA and post-abortion care, and promote dual contraceptive use with highly effective contraceptives.


Assuntos
Aborto Induzido , Atitude , Gravidez não Planejada , Profissionais do Sexo , Aborto Induzido/estatística & dados numéricos , Adolescente , Adulto , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Laos , Modelos Logísticos , Gravidez , Profissionais do Sexo/estatística & dados numéricos , Percepção Social , Mulheres , Adulto Jovem
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