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Global Health, Science and Practice Aug 2019In 2015, the government of Tanzania launched an effort to strengthen the quality of postabortion care (PAC), an integrated health service that includes treatment for...
INTRODUCTION
In 2015, the government of Tanzania launched an effort to strengthen the quality of postabortion care (PAC), an integrated health service that includes treatment for abortion complications and provision of family planning counseling and voluntary services, in 25 facilities in mainland Tanzania and in Zanzibar.
METHODS
To help guide the government's initiative, we conducted a mixed-method study in 2016 using health facility surveys and in-depth interviews with health care workers that offer PAC. Surveys of the 25 facilities assessed the current use of services and readiness to deliver them. Provider performance in PAC was assessed through direct observation of client-provider interactions. In-depth interviews (IDIs) with 30 staff from the facilities provided qualitative information on priorities for PAC quality improvement.
RESULTS
In the 6 months preceding the study, 2,175 PAC clients sought care at the facilities. Of these PAC clients, 55% chose a family planning method, of whom 6% chose a voluntary long-acting reversible contraceptive. The median facility PAC readiness scores were 45% for health centers, 49% for district hospitals, and 61% for regional referral hospitals. Direct observations of manual vacuum aspiration provision for PAC revealed that providers implemented, on average, 69% of the critical clinical steps. For misoprostol provision, PAC providers implemented, on average, 42% of the critical steps. Multilevel influences affected PAC providers' work, often adversely, by shaping their confidence in their technical competency, confusing their role as health care workers and as clients' peers, and coloring their attitudes toward clientele. The PAC providers also felt that their ability to implement their responsibilities was shaped by lapses in essential support and functionality of the health care system, as well as by social and cultural norms.
CONCLUSIONS
Technical assistance approaches that blend training, clinical quality improvement, systems strengthening, and social interventions that address demand-side barriers are needed to ensure providers achieve their potential and are able to deliver high-quality PAC.
Topics: Abortifacient Agents, Nonsteroidal; Aftercare; Attitude of Health Personnel; Capacity Building; Equipment and Supplies; Female; Health Personnel; Humans; Long-Acting Reversible Contraception; Misoprostol; Pregnancy; Quality of Health Care; Tanzania; Vacuum Curettage; Workforce
PubMed: 31455627
DOI: 10.9745/GHSP-D-19-00050 -
Global Health, Science and Practice Aug 2019In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of...
BACKGROUND
In 2015, the government of Tanzania began to strengthen the quality of postabortion care (PAC). Limited research has been conducted to understand clients' perceptions of public sector provision of PAC. Accordingly, we carried out a mixed-method study between April and July 2016, using client surveys and in-depth interviews, both implemented immediately following PAC. Results were used to help guide the government's initiative.
METHODOLOGY
We assessed the quality of PAC in 25 public-sector facilities through a client survey of 412 women. Questions included satisfaction with client-staff interaction, counseling, provider competence, postabortion family planning, accessibility of care, and the facility environment. Based on responses, we developed and validated a scale representing women's overall satisfaction with the quality of care. We conducted bivariate analysis to identify the levels of care associated with clients' ranking of individual and composite measures of the quality of care. We used multivariate ordinal logistic models to assess the relative influence of multilevel factors on clients' overall satisfaction. We coupled our survey with qualitative analysis of in-depth interviews with 30 PAC clients.
RESULTS
Clients reported moderately high levels of satisfaction with the quality of PAC, with an overall mean score of 2.6 on a 4-point scale. Bivariate analysis identified several areas for improvement, including family planning counseling and provision, especially at regional hospitals; pain management; and reduced use of sharp curettage. The factors most strongly associated with satisfaction were advanced parity, receiving care at lower-level facilities, brief waiting periods, and manual vacuum aspiration for treatment of incomplete abortion. Qualitative analysis illuminated how client-provider interactions; pain; desire for counseling and information, especially on family planning; and congested facility environments shape clients' perceptions of the care they received.
CONCLUSIONS
Although clear areas for improvement in public-sector provision of PAC existed at all sites, women were less likely to report satisfaction with care at referral facilities owing primarily to inadequate counseling, delays in receiving PAC treatment after admission, and poor emphasis on postabortion fertility, family planning information, and contraceptive provision. PAC programs should ensure availability of a wide range of contraceptive methods and high-quality family planning counseling, especially at tertiary facilities.
Topics: Abortion, Induced; Abortion, Spontaneous; Adolescent; Adult; Aftercare; Family Planning Services; Female; Hospitals, District; Humans; Middle Aged; Patient Satisfaction; Pregnancy; Public Sector; Quality of Health Care; Surveys and Questionnaires; Tanzania; Tertiary Care Centers; Young Adult
PubMed: 31455626
DOI: 10.9745/GHSP-D-19-00026 -
Global Health, Science and Practice Aug 2019Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of...
BACKGROUND
Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation.
METHODS
Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities.
RESULTS
The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context.
CONCLUSION
These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Aftercare; Capacity Building; Community Participation; Democratic Republic of the Congo; Dilatation and Curettage; Emergencies; Equipment and Supplies; Family Planning Services; Female; Health Services Accessibility; Humans; Misoprostol; Pregnancy; Quality Improvement; Quality of Health Care; Relief Work; Somalia; Vacuum Curettage; Yemen
PubMed: 31455621
DOI: 10.9745/GHSP-D-18-00400 -
Sultan Qaboos University Medical Journal Feb 2019This study aimed to compare the efficacy of oral misoprostol with manual vacuum aspiration (MVA) in first trimester incomplete abortions. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
This study aimed to compare the efficacy of oral misoprostol with manual vacuum aspiration (MVA) in first trimester incomplete abortions.
METHODS
This randomised controlled trial study was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between April 2014 and November 2015. Pregnant women who presented with clinical features of incomplete abortion at a gestational age of 13 weeks or less were included. Patients who had profuse vaginal bleeding, an intrauterine device , signs of pelvic infections or who were younger than 18 years old and had no accompanying adults to give informed consent were excluded. A total of 200 participants were randomly and equally allocated to either the MVA or misoprostol treatment group. The treatment group were given 600 μg of misoprostol orally. The primary outcome measure was complete uterine evacuation, while secondary outcome measures included the need for additional surgical evacuation for failed treatment, adverse effects/complications, acceptability of and satisfaction with the treatment.
RESULTS
Both misoprostol and MVA had high complete evacuation rates, yet MVA was significantly higher (99% versus 83%, relative risk [RR]: 0.84, confidence interval [CI]: 0.766-0.918; <0.001). Significantly more women in the misoprostol group required additional MVA for failed treatment than in the MVA treatment group (17% versus 1%, RR: 16.67, CI: 2.260-12.279; <0.001). No significant difference was found between the misoprostol and MVA treatment groups in terms of satisfaction (92.7% versus 89.8%, RR: 1.04, CI: 0.946-1.127; = 0.473).
CONCLUSION
Treatments with misoprostol and MVA had high complete uterine evacuation rates, as well as high rates of acceptability and satisfaction. However, MVA had a significantly higher complete evacuation rate than misoprostol.
Topics: Abortion, Incomplete; Abortion, Induced; Adult; Female; Humans; Misoprostol; Nigeria; Tertiary Care Centers; Treatment Outcome; Vacuum Curettage
PubMed: 31198594
DOI: 10.18295/squmj.2019.19.01.008 -
Medical Archives (Sarajevo, Bosnia and... Feb 2019Cesarean scar pregnancy is potentially life-threatening condition because of heavy complications and includes adherent placenta: accreta, increta or percreta as a result...
INTRODUCTION
Cesarean scar pregnancy is potentially life-threatening condition because of heavy complications and includes adherent placenta: accreta, increta or percreta as a result of deep placental invasion.
AIM
To present a rare case of ectopic cesarean scar pregnancy combined with placenta percreta in 38-year old woman who undergone previous cesarean section delivery.
CASE REPORT
A multiparous woman aged 38 years with prior cesarean section delivery, admitted first time to the Clinic in 7th week of gestation, due to her medical record (light bleeding). Diagnosis was: graviditas hbd 7, gemellar pregnancy, blighted ovum gemellus I, graviditas isthmico-cervicalis gemellus II. Due to diagnosis it was performed vacuum aspiration et curettage and woman leaved hospital same day. One month later same woman was admitted again to the Clinic due to bleeding and ultrasound finding suspicious to residual trophoblastic tissue. Beta human chorionic gonadotropin serum concentration at the day of admittance was 8,419 IU/ml. Ultrasound finding showed inhomogeneous supracervical formation with dimension 2,73x1,89 cm with increased vascularity and resistant index 0.36 and suspicious placenta increta. We made decision to surgery, and performed hysterectomy in view of heavy intraoperative haemorrhage. Woman was discharged at fifth day after surgery in good condition. Histological finding showed cervical pregnancy complicated with placenta percreta parietis isthmicocervicalis of the uterus.
CONCLUSION
We showed the importance of early and opportune diagnosis of cervical pregnancy specially complicated with one of kind of throphoblastic disease, to prevent life-threatening complication.
Topics: Adult; Cesarean Section; Cicatrix; Female; Humans; Hysterectomy; Placenta Accreta; Pregnancy; Pregnancy, Ectopic
PubMed: 31097863
DOI: 10.5455/medarh.2019.73.58-60 -
Reproductive Health Feb 2019Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical...
BACKGROUND
Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended.
METHODS
The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced.
RESULTS
Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work.
CONCLUSION
Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.
Topics: Abortion, Incomplete; Abortion, Induced; Attitude of Health Personnel; Health Knowledge, Attitudes, Practice; Health Personnel; Humans; Malawi
PubMed: 30782201
DOI: 10.1186/s12978-019-0683-z -
International Journal of Hyperthermia :... 2019Cervical pregnancy (CP) is a rare type of ectopic pregnancy and is considered to be a life-threatening condition due to the risk of severe hemorrhage. Unfortunately, no...
OBJECTIVE
Cervical pregnancy (CP) is a rare type of ectopic pregnancy and is considered to be a life-threatening condition due to the risk of severe hemorrhage. Unfortunately, no consensus on standard conservative treatment for CP has been established. The study objective was to evaluate the efficacy and safety of high-intensity focused ultrasound (HIFU) followed by suction curettage for cervical pregnancy.
METHOD
Three patients with cervical pregnancy undergoing high-intensity focused ultrasound followed by suction curettage were analyzed. Patient age, gestational age, endocervical mass, serum human chorionic gonadotrophin (HCG) level, blood loss, and time for normal menstruation recovery were recorded.
RESULTS
Three patients with cervical pregnancy were successfully treated with HIFU followed by suction curettage. After HIFU treatment, the fetal cardiac activity disappeared or the blood flow in the pregnancy tissue significantly decreased. The termination of the cervical pregnancy of all three patients was performed successfully without heavy bleeding. The estimated blood loss was 10-20 ml. The time for menstruation recovery was 30-45 days. No obvious complications of HIFU were observed in these cases.
CONCLUSION
High-intensity focused ultrasound followed by suction curettage seems to be considered as conservative management for patients who desire to preserve their uterus.
Topics: Adult; Extracorporeal Shockwave Therapy; Female; Humans; Pregnancy; Pregnancy, Ectopic; Vacuum Curettage
PubMed: 30676110
DOI: 10.1080/02656736.2018.1563914 -
Turk Patoloji Dergisi 2019The purpose of our study was to assess trophoblastic and uterine sufficiency in miscarriage pathogenesis with immunohistochemical methods and to determine if they could...
OBJECTIVE
The purpose of our study was to assess trophoblastic and uterine sufficiency in miscarriage pathogenesis with immunohistochemical methods and to determine if they could be used as a screening tool for the risk of miscarriage in the future.
MATERIAL AND METHOD
Placental tissue specimens that were comprised of 20 spontaneous abortions, 23 voluntarily terminated (induced) abortions, and 12 tubal pregnancies were included in this study. Trophoblastic cells and implantation area were evaluated for staining with EGFR-1, MMP-3, and MMP-9 by immunohistochemistry.
RESULTS
EGFR-1 expression was more intense and diffuse in decidual cells in the placental bed of spontaneous abortion specimens; this difference was statistically significant (P=0.004). MMP-3 expression was markedly increased in villous and extravillous trophoblastic cells in induced abortions; the difference between the groups was found to be statistically significant (P values ranged from < 0.01 to 0.005). MMP-9 expression tended to be higher in spontaneous abortion and tubal pregnancy specimens, and the results were statistically significant as P values were lower than 0.01.
CONCLUSION
Higher EGFR-1 expression in the decidual tissue of spontaneous abortion specimens suggests that EGFR-1 triggers the migration of extravillous trophoblasts, leading to their destructive invasion. Similarly, MMP-9 immunopositivity might be indicative of aggressive invasion contributing to spontaneous abortion pathogenesis. Relatively high levels of MMP-3 expression in induced abortion specimens used as a control group might be a predictor of successful implantation, whereas its decreased expression might be indicative of risk for pregnancy loss.
Topics: Abortion, Induced; Abortion, Spontaneous; Adult; Chorionic Villi; Decidua; ErbB Receptors; Female; Humans; Immunohistochemistry; Matrix Metalloproteinase 3; Matrix Metalloproteinase 9; Placenta; Pregnancy; Pregnancy, Tubal; Trophoblasts; Vacuum Curettage; Young Adult
PubMed: 30596394
DOI: 10.5146/tjpath.2018.01432 -
PloS One 2018Abortion-related mortality accounts for 8% of all global maternal deaths and 97% of the estimated 25 million unsafe abortions performed each year occur in low- and...
BACKGROUND
Abortion-related mortality accounts for 8% of all global maternal deaths and 97% of the estimated 25 million unsafe abortions performed each year occur in low- and middle-income countries. Haiti has the highest rate of maternal mortality in the western hemisphere and to further understand the circumstances of induced abortion in Haiti, the current work uses data from the 2012 Demographic and Health Survey (DHS) to describe the methods of induced abortion in Haiti between 2007-2012 and to identify potential factors associated with use of different abortion methods.
METHODS
This is a secondary analysis of nationally representative cross-sectional data from the 2012 Haitian DHS, a two-stage cluster randomized household survey. Analysis included descriptive statistics on participant demographics, methods of abortion, and location of / assistant for the abortion. Multivariate regression was conducted to determine if demographic characteristics were associated with: 1) increased or decreased odds of having an abortion; or 2) increased or decreased odds of reporting an evidence based or non-evidence based method of abortion.
RESULTS
Among the 14,287 women of childbearing age who completed the 2012 Haiti DHS survey, 289 women reported having an induced abortion in the previous five years. Recommended methods, manual vacuum aspiration (MVA) or misoprostol alone, were used in 26.6% of the abortions (n = 77). Additionally, 13.8% (n = 40) of abortions used these recommended methods in combination with a non-evidenced based method such as injections, plants or tablets. A total of 92 women had a dilation and curettage (D&C) abortion, either alone (n = 77) or in combination with another method (n = 15) and over a quarter (n = 80) of reported abortions were conducted by non-evidence based methods (n = 80). A majority of abortions using a recommended method were assisted by a relative/friend (n = 28) or were unassisted (n = 34). Most abortions occurred in private homes (n = 174) with hospitals/clinics being the second most common location (n = 84). Women in the middle (OR = 3.3, 95% CI = 2.0-5.6) and highest (OR = 7.4, 95% CI = 4.4-12.3) wealth brackets were more likely to have had an abortion in comparison to women in the lowest wealth bracket. Women who had ever been in a marital union were more likely to have had an abortion than those who had not. The only demographic factor predictive of aborting using a recommended method was living in an urban area, with urban-dwelling women being less likely to use a recommended abortion method (OR = 0.4, 95% CI = 0.2-0.9) in comparison with women living in rural settings.
CONCLUSION
In a nationally representative survey in Haiti, 2% of women of childbearing age reported having an abortion in the five years prior to the survey. A large proportion of these abortions were carried out using non-evidence based methods and over half occurred outside of the formal health care system. Understanding women's attitudes, knowledge and barriers around abortion is paramount to improving knowledge and access to evidence-based abortion care in an effort to decrease maternal morbidity and mortality in Haiti.
Topics: Abortion, Induced; Adolescent; Adult; Attitude; Cross-Sectional Studies; Female; Haiti; Humans; Income; Knowledge; Middle Aged; Multivariate Analysis; Pregnancy; Surveys and Questionnaires; Urban Population; Young Adult
PubMed: 30408133
DOI: 10.1371/journal.pone.0206967 -
Family Medicine Oct 2018The goal of this study was to explore family medicine residents' experiences with abortion training and identify positive and negative influences, and facilitators and...
BACKGROUND AND OBJECTIVES
The goal of this study was to explore family medicine residents' experiences with abortion training and identify positive and negative influences, and facilitators and barriers to providing abortion care.
METHODS
We conducted a qualitative study of recent graduates of an urban family medicine residency in the Northeast United States with an opt-out abortion curriculum. Individual recorded interviews were conducted with two classes of graduated residents until data saturation was reached. Data were coded and interpreted by both authors using the template analysis method.
RESULTS
Twenty residents completed interviews. Most trainees had limited or no abortion exposure prior to residency but were open to learning abortion care. By graduation, residents reported confidence in providing options counseling for unintended pregnancy. Overall, residents felt more comfortable providing medication abortion than aspiration abortion. Many reported feeling less emotional reaction to medication abortion and noted more technical and logistical barriers to learning aspiration abortion. Logistical barriers impede integration of medication abortion into practice for many, but were perceived to be less difficult to overcome than barriers to aspiration abortion integration. All participants agreed abortion care fits into the scope of primary care. Due to a variety of barriers, few of those who had not previously planned to become abortion providers after graduation incorporated it in their practice.
CONCLUSIONS
Abortion training prepared residents to counsel women with unintended pregnancy, but numerous barriers inhibit integration of abortion care into practice. Given limited abortion training resources and fewer perceived barriers to medication abortion provision, family medicine residencies may consider focusing training on medication abortion.
Topics: Abortifacient Agents; Abortion, Induced; Attitude of Health Personnel; Continuity of Patient Care; Curriculum; Family Practice; Humans; Practice Patterns, Physicians'; Qualitative Research; Vacuum Curettage
PubMed: 30307587
DOI: 10.22454/FamMed.2018.529396