Mandira Paul


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    Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a checklist in Rajasthan, India: study protocol and intervention adaptation of a randomized controlled trial

    Mandira Paul2, Kirti Iyengar1 ,4, Sharad Iyengar4, Kristina Gemzell-Danielsson1, Birgitta Essén2, Marie Klingberg-Allvin3 ,1 1Karolinska Institutet, Stockholm, Sweden, 2Uppsala University, Uppsala, Sweden, 3Dalarna University, Falun, Sweden, 4Action Research, Training for Health (ARTH) Society, Udaipur, India -

    Background: The WHO suggests that simplification of the medical abortion regimen will contribute to an increased acceptability among women and providers. It is expected that home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic. This study protocol describes an RCT that aims to evaluate the efficacy of home-based self-assessment after a medical abortion and the acceptability and feasibility of the intervention in a low-resource setting. Method/Design: The study is a randomised, controlled, non-superiority trial that will evaluate the effectiveness and acceptability of self-assessment using a low-sensitivity pregnancy test and a checklist two weeks after medical abortion. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the self-assessment group will use the low-sensitivity pregnancy test and the checklist at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. To ensure feasibility of the self-assessment intervention an adaptation phase took place at the selected study sites before study initiation. This was to optimize and tailor-make the intervention and the study procedures and resulted in the development of a pictorial instruction sheet on how to use the low-sensitivity pregnancy test and the checklist of danger signs after a medical abortion. Discussion: In this paper, we will describe the study protocol for a randomized controlled trial investigating the efficacy of simplified follow-up in terms of home-based self-assessment, two weeks after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor.

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    Task sharing in post-termination of pregnancy care
    at district level in Uganda; healthcare providers’
    perception on safe TOP, post-TOP care and
    contraceptive counselling – an exploratory study
    Allvin, MK1; Paul, M1; Gemzell-Danielsson, K1;
    Kiggundu, C2
    1 Department of Obstetrics and Gyanecology Karolinska Institutet,
    Stockholm, Sweden; 2 Mulago University Hospital, Kampala, Uganda
    Background: Termination of pregnancy (TOP) is restricted in
    Uganda and poor access to family planning results in unwanted
    pregnancies forcing women to have unsafe TOPs and thus posing
    a great burden on the Ugandan health system. Post-TOP care is
    implemented and unofficial task shifting is taking place as a
    pragmatic response to the workload.

    Objective: To explore the healthcare providers’ perception on
    post-TOP care, with regard to professional competences, medical
    and surgical methods, contraceptive counselling and task shifting/
    sharing in post-TOP care.
    Methods: In-depth interviews (n = 27) with healthcare providers
    participating in post-TOP care were conducted in seven health
    facilities in the Central region of Uganda. Data was organised
    using thematic analysis with an inductive approach.
    Results: Post-TOP care was perceived necessary, however
    controversial, and together with poor conditions it provoked
    frustration, mainly among the midwives. Task sharing was
    generally implemented and midwives were identified as the main
    providers. Different uterine evacuation skills were recognised and
    midwives would sometimes perform interventions not approved
    by hospital guidelines, due to absence of doctors. Misoprostol was
    rarely used or accessible at district level, however those with
    experience perceived it efficient and safe. An overall demand and
    need for further training was identified.
    Conclusions: Developing policies and service guidelines in order
    to implement evidence based use of misoprostol in post-TOP care
    as well as provision of in-service training is recommended.
    Implementation of official task shifting in post-TOP care would
    further be a systematic approach to improve quality of care and
    accessibility of services in order to reduce TOP-related mortality
    and morbidity.