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Paul, M., Essén, B., Sariola, S., Iyengar, S., Soni, S. & Klingberg Allvin, M. (2017). Negotiating Collective and Individual Agency: A Qualitative Study of Young Women's Reproductive Health in Rural India.. Qualitative Health Research, 27(3), 311-324
Open this publication in new window or tab >>Negotiating Collective and Individual Agency: A Qualitative Study of Young Women's Reproductive Health in Rural India.
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2017 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 27, no 3, p. 311-324Article in journal (Refereed) Published
Abstract [en]

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-266827 (URN)10.1177/1049732315613038 (DOI)000394093500002 ()26531879 (PubMedID)
Funder
Swedish Research Council, 2011-3525Wellcome trust, 096527
Available from: 2015-11-11 Created: 2015-11-11 Last updated: 2017-12-01Bibliographically approved
Iyengar, K., Klingberg-Allvin, M., Iyengar, S. D., Paul, M., Essén, B. & Gemzell-Danielsson, K. (2016). Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica, 95(2), 173-181
Open this publication in new window or tab >>Home use of misoprostol for early medical abortion in a low resource setting: secondary analysis of a randomized controlled trial
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2016 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 95, no 2, p. 173-181Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Although home use of misoprostol for early medical abortion is considered to be safe, effective and feasible, it has not become standard service delivery practice. The aim of this study was to compare the efficacy, safety, and acceptability of home use of misoprostol as compared to clinic misoprostol in a low-resource setting.

MATERIAL AND METHODS: This was a secondary analysis of a randomised controlled trial conducted in 6 primary care clinics in India. Women seeking medical abortion up to 9 gestational weeks (n= 731) received mifepristone in the clinic, and were allocated either to home or clinic administration of misoprostol. Follow-up contact was after 10-15 days.

RESULTS: Of 731 participants, 73% were rural and 55% had no formal education. Complete abortion rates in the home and clinic misoprostol groups were 94.2% and 94.4% respectively. The rate of adverse events was similar in both groups (0.3%). A greater proportion of home users (90.2%) said that they would opt for misoprostol at home in the event of a future abortion, than the proportion of clinic users (79.7%) that would opt for misoprostol at the clinic, in a similar situation (p=0.0002). Ninety six percent women using misoprostol at home or in the clinic were satisfied with their abortion experience.

CONCLUSIONS: Home-use of misoprostol for early medical abortion is as effective and acceptable as clinic use, in low resource settings. Women should be offered a choice of this option regardless of distance of their residence from the clinic and communication facilities.

Keywords
Termination of pregnancy; home administration; mifepristone; misoprostol; medical abortion; low-resource setting; India
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-268452 (URN)10.1111/aogs.12815 (DOI)000368004300006 ()26565074 (PubMedID)
Funder
Sida - Swedish International Development Cooperation AgencySwedish Research Council, 2011-3525
Available from: 2015-12-04 Created: 2015-12-04 Last updated: 2017-12-01Bibliographically approved
Paul, M., Iyengar, K., Essén, B., Gemzell-Danielsson, K., Iyengar, S. D., Bring, J., . . . Klingberg-Allvin, M. (2015). Acceptability of Home-Assessment PostMedical Abortion and Medical Abortion in aLow-Resource Setting in Rajasthan, India: Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial. PLOS ONE, 10(9), Article ID e0133354.
Open this publication in new window or tab >>Acceptability of Home-Assessment PostMedical Abortion and Medical Abortion in aLow-Resource Setting in Rajasthan, India: Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial
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2015 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 10, no 9, article id e0133354Article in journal (Refereed) Published
Abstract [en]

Background

Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education.

Objective

To investigate women’s acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India.

Design

Secondary outcome of a randomised, controlled, non-inferiority trial.

Setting

Outpatient primary health care clinics in rural and urban Rajasthan, India.

Population

Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years.

Methods

Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1:1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible.

Main Outcome Measures

Women’s acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups.

Results

731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001).

Conclusion

Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women’s preference should be offered to foster women’s reproductive autonomy.

National Category
Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-262580 (URN)10.1371/journal.pone.0133354 (DOI)000360437700006 ()
Funder
Swedish Research Council, 2011-3525Sida - Swedish International Development Cooperation Agency
Available from: 2015-09-16 Created: 2015-09-16 Last updated: 2021-06-14
Iyengar, K., Paul, M., Iyengar, S. D., Klingberg-Allvin, M., Essén, B., Bring, J., . . . Gemzell-Danielsson, K. (2015). Self-assessment of the outcome of early medical abortion versus clinic follow-up in India: a randomised, controlled, non-inferiority trial. LANCET GLOBAL HEALTH, 3(9), E537-E545
Open this publication in new window or tab >>Self-assessment of the outcome of early medical abortion versus clinic follow-up in India: a randomised, controlled, non-inferiority trial
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2015 (English)In: LANCET GLOBAL HEALTH, ISSN 2214-109X, Vol. 3, no 9, p. E537-E545Article in journal (Refereed) Published
Abstract [en]

Background The need for multiple clinical visits remains a barrier to women accessing safe legal medical abortion services. Alternatives to routine clinic follow-up visits have not been assessed in rural low-resource settings. We compared the effectiveness of standard clinic follow-up versus home assessment of outcome of medical abortion in a low-resource setting. Methods This randomised, controlled, non-inferiority trial was done in six health centres (three rural, three urban) in Rajasthan, India. Women seeking early medical abortion up to 9 weeks of gestation were randomly assigned (1:1) to either routine clinic follow-up or self-assessment at home. Randomisation was done with a computer-generated randomisation sequence, with a block size of six. The study was not blinded. Women in the home-assessment group were advised to use a pictorial instruction sheet and take a low-sensitivity urine pregnancy test at home, 10-14 days after intake of mifepristone, and were contacted by a home visit or telephone call to record the outcome of the abortion. The primary (non-inferiority) outcome was complete abortion without continuing pregnancy or need for surgical evacuation or additional mifepristone and misoprostol. The non-inferiority margin for the risk difference was 5%. All participants with a reported primary outcome and who followed the clinical protocol were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01827995. Findings Between April 23, 2013, and May 15, 2014, 731 women were recruited and assigned to clinic follow-up (n=366) or home assessment (n=365), of whom 700 were analysed for the main outcomes (n=336 and n=364, respectively). Complete abortion without continuing pregnancy, surgical intervention, or additional mifepristone and misoprostol was reported in 313 (93%) of 336 women in the clinic follow-up group and 347 (95%) of 364 women in the home-assessment group (difference -2.2%, 95% CI -5.9 to 1.6). One case of haemorrhage occurred in each group (rate of adverse events 0.3% in each group); no other adverse events were noted. Interpretation Home assessment of medical abortion outcome with a low-sensitivity urine pregnancy test is non-inferior to clinic follow-up, and could be introduced instead of a clinic follow-up visit in a low-resource setting.

National Category
Occupational Health and Environmental Health Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-263448 (URN)000360559500019 ()26275330 (PubMedID)
Funder
Swedish Research Council, 2011-3525
Available from: 2015-10-06 Created: 2015-09-30 Last updated: 2020-07-13Bibliographically approved
Paul, M. (2015). Simplifying Reproductive Health in Low-Resource Settings: Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>Simplifying Reproductive Health in Low-Resource Settings: Access to medical abortion and contraceptive choice, the importance of gendered structures in Rajasthan
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

India introduced family planning in the ‘50s, legalized abortion in the ‘70s, and accomplished a remarkable drop in maternal mortality and fertility since 1990. Nevertheless, abortions account for a large proportion of maternal deaths, and sterilization is the most frequently used contraception. This thesis aims to identify the means to simplify and increase access to reproductive health in low-resource settings, focusing on abortion and contraception in Rajasthan.

A randomized controlled trial compared simplified follow-up, where women assess their abortion outcome at home after early medical abortion, with in-clinic follow-up. Additionally, contraceptive use was compared between study groups post-abortion. In order to explore young women’s opportunities to access reproductive health services in the area, we conducted in-depth interviews with recently-married women.

Women in the home-assessment group preferred home-assessment in the future to a greater extent than the women in the clinic follow-up group, who preferred in-clinic follow-up. Complete abortions were reported in 95% of women in the ‘home-assessment group’ and 93% in the ‘in-clinic group’, suggesting that efficacy of simplified follow-up is non-inferior to in-clinic follow-up. A majority (81%) of women carried out the pregnancy test and found it easy to use. Women (96%) were satisfied with their abortion. There were no differences in contraceptive use between study groups at three months; however, women in the ‘in-clinic group’ were most likely to initiate contraception at two weeks. A majority of women preferred the three-month injection, while only 4% preferred sterilization. The recently-married women considered reversible contraception to be unfeasible due to misconceptions and taboos, yet women wanted effective contraception because their current use of traditional methods resulted in unintended pregnancies. Abortions were common, and were procured from private or informal providers.

Allowing women to take an active role in reproductive health services can enable simplification of, and access to, reproductive services in low-resource settings as well as in other settings. Simplifying medical abortion, providing contraception ‘intra-abortion’, and offering a context-appropriate and effective means of contraception, creates a great potential to increase access to reproductive health services and can result in a more equal society where women, and men, can attain their sexual and reproductive rights.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. p. 144
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1163
Keywords
Medical abortion, Contraception, Access, Simplified, Gender, Sexual and reproductive health and rights, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy Obstetrics, Gynecology and Reproductive Medicine
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-267167 (URN)978-91-554-9414-8 (ISBN)
Public defence
2016-01-11, Gustavianum, Akademigatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2015-12-14 Created: 2015-11-18 Last updated: 2018-06-04
Paul, M., Danielsson, K. G., Essén, B. & Allvin, M. K. (2015). The importance of considering the evidence in the MTP 2014 Amendment debate in India: unsubstantiated arguments should not impede improved access to safe abortion. Global Health Action, 8, 27512
Open this publication in new window or tab >>The importance of considering the evidence in the MTP 2014 Amendment debate in India: unsubstantiated arguments should not impede improved access to safe abortion
2015 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 27512-Article in journal (Refereed) Published
Abstract [en]

With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-249288 (URN)10.3402/gha.v8.27512 (DOI)000352006700001 ()25828071 (PubMedID)
Available from: 2015-04-13 Created: 2015-04-13 Last updated: 2017-12-04Bibliographically approved
Paul, M., Gemzell-Danielsson, K., Kiggundu, C., Namugenyi, R. & Klingberg-Allvin, M. (2014). Barriers and facilitators in the provision of post-abortion care at district level in central Uganda: a qualitative study focusing on task sharing between physicians and midwives. BMC Health Services Research, 14(1), 28
Open this publication in new window or tab >>Barriers and facilitators in the provision of post-abortion care at district level in central Uganda: a qualitative study focusing on task sharing between physicians and midwives
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2014 (English)In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, no 1, p. 28-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians' and midwives' perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care.

METHODS:

In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach.

RESULTS:

Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified.

CONCLUSIONS:

Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-217110 (URN)10.1186/1472-6963-14-28 (DOI)000330248300002 ()24447321 (PubMedID)
Available from: 2014-01-29 Created: 2014-01-29 Last updated: 2022-09-15Bibliographically approved
Paul, M., Iyengar, K., Iyengar, S., Gemzell-Danielsson, K., Essén, B. & Klingberg-Allvin, M. (2014). Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India: study protocol and intervention adaptation of a randomised control trial. BMC Women's Health, 14, 98
Open this publication in new window or tab >>Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India: study protocol and intervention adaptation of a randomised control trial
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2014 (English)In: BMC Women's Health, E-ISSN 1472-6874, Vol. 14, p. 98-Article in journal (Refereed) Published
Abstract [en]

BACKGROUND

The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a 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.

METHODS/DESIGN

This study protocol describes a study that is a randomised, controlled, non-superiority trial. Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. The randomisation list will be generated using a computerized random number generator and opaque sealed envelopes with group allocation will be prepared. Randomization of the study participants will occur after the first clinical encounter with the doctor. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet 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. The primary objective of the study this study protocol describes is to evaluate the efficacy of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This resulted in an optimized, tailor-made intervention and in the development of the pictorial instruction sheet with a guide on how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion.

DISCUSSION

In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days 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.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01827995. Registered 04 May 2013.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-230832 (URN)10.1186/1472-6874-14-98 (DOI)000340652200001 ()25127545 (PubMedID)
Funder
Swedish Research Council, 2011-3525
Available from: 2014-08-29 Created: 2014-08-29 Last updated: 2023-08-28Bibliographically approved
Paul, M., Iyengar D, S., Essén, B., Gemzell-Danielsson, K., Iyengar, K., Bring, J. & Klingberg-Allvin, M. Does mode of follow-up influence contraceptive use post-medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial.
Open this publication in new window or tab >>Does mode of follow-up influence contraceptive use post-medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial
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(English)In: Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-267166 (URN)
Available from: 2015-11-18 Created: 2015-11-18 Last updated: 2020-07-13
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-5841-5984

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