Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return.

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.

Main findings: The two-decade long collaboration between Sweden and East Africa, funded by the Swedish government, has resulted in important partnerships, research findings, and advancements within sexual and reproductive health and rights in East Africa.Added knowledge: The Swedish government is now cutting funding for development research, which jeopardises the progress made so far.Global health impact for policy and action: Governments need to prioritise women's sexual and reproductive health and rights.

Facility-based maternal deaths: Their prevalence, causes and underlying circumstances. A mixed method study from the national referral hospital of Somaliland.

OBJECTIVE: Somaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital. METHOD: A hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo. RESULTS: From the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital. CONCLUSION: The referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced.

Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital.

BACKGROUND: In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members. OBJECTIVE: To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor's decision were also explored. METHODS: Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1-3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression. RESULTS: Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13-2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32-0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001). CONCLUSIONS: In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

Qualitative study of the roles of midwives in the provision of sexual and reproductive healthcare services in the Somaliland health system.

OBJECTIVES: To explore midwives' perspectives in providing sexual reproductive healthcare services in the Somaliland health system. METHODS: An exploratory qualitative design using focus group discussions (n=6) was used. The study was conducted in the capital of Somaliland, Hargeisa, at six maternal and child healthcare centres that provide sexual and reproductive healthcare (SRH) services. Qualified midwives (n=44) who had been working in the maternal and child health centres for a minimum of 1 year were recruited to participate, and only one did not participate due to illness. RESULTS: The results showed that Somaliland midwives face multiple challenges from a lack of formal arrangements, primarily written guidelines and policies, that explicitly define their role as healthcare professionals, which impact the quality of care they provide. They also reported feeling unsafe when practising according to their professional scope of practice due to challenging cultural norms, customary traditions and Somaliland's legal system. Finally, the midwives called for support, including training, institutional protection and psychological support, to enhance their ability and fulfil their role in SRH services in Somaliland. CONCLUSION: Midwives are essential to the provision of equitable SRH services to women and girls, yet are not fully supported by policies, laws or institutions, often living in fear of the consequences of their behaviours. Our research highlights the importance of understanding the context of Somaliland midwifery in order to better support the development of the midwifery workforce, stronger governance structures and midwifery leadership. Appropriately addressing these challenges faced by midwives can better sustain the profession and help to improve the quality of care provided to women and girls and ultimately enhance their reproductive health outcomes.

The implementation of a culturally tailored parenting support programme for Somali immigrant parents living in Sweden-A process evaluation.

BACKGROUND: Parental support programmes aim to strengthen family functioning and the parent-child relationship and to promote the mental health of children and parents. However, there is a lack of knowledge on how parenting support programmes can be implemented for newly arrived immigrant parents. This process evaluation describes the implementation of a successful parenting programme for immigrant parents from Somalia and identifies key components of the implementation process with a focus on Reach, Adaptation, and Fidelity of Ladnaan intervention. METHOD: This process evaluation considered context, implementation and mechanism of impact, in accordance with the Medical Research Council's guidance. Data were collected through focus group discussions, a questionnaire, attendance lists, field and reflection notes and observations of the sessions. The data were then analysed using content analysis and descriptive statistics. RESULTS: Of the 60 parents invited to the parenting programme, 58 participated in the sessions. The study showed that involving key individuals in the early stage of the parenting programme's implementation facilitated reaching Somali-born parents. To retain the programme participants, parents were offered free transportation. The programme was implemented and delivered as intended. A majority of the parents were satisfied with the programme and reported increased knowledge about children's rights and the support they could seek from social services. CONCLUSIONS: This study illustrates how a parenting support programme can be implemented for Somali-born parents and provides guidance on how to attract immigrant parents to and engage them in participating in parenting support programmes.

Healthcare providers' experiences of comprehensive emergency obstetric care in Somaliland: An explorative study with focus on cesarean deliveries.

OBJECTIVE: This study aimed to explore the experiences of healthcare providers (HCPs) regarding the provision of emergency obstetric care (EmOC) with a focus on cesarean deliveries in a referral hospital and maternal and child health centers in Somaliland. METHODS: An exploratory qualitative approach using focus group discussions was employed at the main referral and teaching hospital and four maternal and child health centers in Hargeisa, Somaliland. Twenty-eight HCPs were divided into groups of 6-8 for discussions lasting 1 to 2 h. All HCPs included in the study had experiences with the provision of EmOC. Data were analyzed using thematic analysis. RESULTS: Collective family decision making was identified by HCPs as a barrier to the provision of EmOC. This tradition of decision making at a group level was perceived as time-consuming and delayed HCPs from obtaining informed consent for EmOC. Low socioeconomic status and poor knowledge about maternal healthcare among users affected care seeking among women. Suboptimal EmOC at the hospital was reported to be due to miscommunication, inadequate interprofessional collaboration and lack of infrastructure. CONCLUSIONS: HCPs encountered difficulties with the provision of EmOC. A broad array of strategies targeting the community and healthcare system is needed, including training of HCPs on intracultural communication competence, interprofessional collaboration and use of alternative birth methods other than CS. Antenatal care can be used to prepare families for potential obstetric emergencies and as an opportunity to obtain written informed consent.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda.

BACKGROUND: To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda. METHODS: Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13-18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 µg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was -5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073. FINDINGS: Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was -2·3% (95% CI -4·4 to -0·3), and within our predefined equivalence range (-5% to 5%). Two women in the midwife group received blood transfusion. INTERPRETATION: Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care. FUNDING: Swedish Research Council and THRiVE-2.

Incidence and causes of severe maternal outcomes in Somaliland using the sub-Saharan Africa maternal near-miss criteria: A prospective cross-sectional study in a national referral hospital.

OBJECTIVE: To describe the incidence and causes of severe maternal outcomes and the unmet need for life-saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland. METHODS: A prospective cross-sectional study was conducted from April 15, 2019 to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data were collected using the World Health Organization (WHO) and sub-Saharan Africa (SSA) maternal near-miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions, and ratios. RESULTS: The MNM ratios were 56 (SSA criteria) and 13 (WHO criteria) per 1000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric hemorrhage (13%), pregnancy-related infection (10%), and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum hemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after 3 h. CONCLUSION: There is a need to improve the quality of maternal health services through implementation of evidence-based obstetric interventions and continuous in-service training for healthcare providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.

A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs-a qualitative study among multiparous women in Somaliland.

BACKGROUND: Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women's choice of place of birth. OBJECTIVE: In this study, we explore multipara women's needs and preferences when choosing the place of birth. METHOD: An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years. RESULTS: The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth. CONCLUSION: To meet women's needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Impact of a culturally tailored parenting programme on the mental health of Somali parents and children living in Sweden: a longitudinal cohort study.

OBJECTIVES: This study aimed to evaluate the long-term impact (3-year follow-up) of a culturally tailored parenting support programme (Ladnaan) on the mental health of Somali-born parents and their children living in Sweden. METHODS: In this longitudinal cohort study, Somali-born parents with children aged 11-16 were followed up 3 years after they had participated in the Ladnaan intervention. The Ladnaan intervention comprises two main components: societal information and the Connect parenting programme delivered using a culturally sensitive approach. It consists of 12 weekly group-based sessions each lasting 1-2 hours. The primary outcome was improved mental health in children, as measured by the Child Behaviour Checklist (CBCL). The secondary outcome was improved mental health in parents, as measured by the General Health Questionnaire-12. Data were collected from the parent's perspective. RESULTS: Of the 60 parents who were originally offered the intervention, 51 were included in this long-term follow-up. The one-way repeated measures (baseline to the 3-year follow-up) analysis of variance for the CBCL confirmed maintenance of all the treatment gains for children: total problem scores (95% CI 11.49 to 18.00, d=1.57), and externalising problems (95% CI 2.48 to 5.83, d=0.86). Similar results were observed for the parents' mental health (95% CI 0.40 to 3.11, d=0.46). CONCLUSION: Positive changes in the mental health of Somali-born parents and their children were maintained 3 years after they had participated in a parenting support programme that was culturally tailored and specifically designed to address their needs. Our findings highlight the long-term potential benefits of these programmes in tackling mental health issues in immigrant families. TRIAL REGISTRATION NUMBER: NCT02114593.

A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh.

BACKGROUND: Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers' perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox's Bazar, Bangladesh and identifies barriers and facilitators in service provision. METHOD: In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach. RESULTS: The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care. CONCLUSION: The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers' personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

Contraceptive uptake among post-abortion care-seeking women with unplanned or planned pregnancy in western Kenya.

OBJECTIVES: To investigate contraceptive uptake among PAC-seeking women reporting either planned pregnancies (PP) or unplanned pregnancies (UP) and to identify factors associated with UP. STUDY DESIGN: This was a sub-study nested in randomised controlled trial (RCT) on women who sought PAC in a low-resource setting in western Kenya. The analysis was based on 807 women who were followed up at 7-10 days and by 472 women at 3 months. MAIN OUTCOME MEASURES: Descriptive statistics and a binary logistic regression model with odds ratios (OR) and 95% confidence intervals (CI) were used. RESULTS: Of the 807 women, 375 (46.3%) reported UP, and 432 (53.3%) PP. Most women, regardless of reported pregnancy intention, agreed to start using contraceptive methods: UP 273 (72.8%) and PP 338 (78.2%), respectively, P = 0.072. Independent factors associated with UP were young age (14-20 years; OR 1.177; 95% CI, 1.045-2.818; P = 0.033), unmarried status (OR 9.149; 95% CI, 5.719-14.638; P < 0.001), nulliparity (OR 1.968; 95% CI, 1.287-3.008; P = 0.002), concealed pregnancy (OR 7.708; 95% CI, 3.299-18.012; P < 0.001) and absence of a partner at the clinic visit (OR 3.174; 95% CI, 2.214-4.552; P < 0.001). At 3-month follow-up, there was no difference in contraceptive use between the UP group (161; 77.4%) and the PP group (193; 73.7%), P = 0.350. CONCLUSION: Contraceptive counselling should be systematically offered to all PAC-seeking women, regardless of their stated pregnancy intention. Adolescents, unmarried women, nulliparous, women with concealed pregnancy and attending the PAC clinic without a partner should be given extra attention by PAC providers offering contraceptive counselling.

Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers.

OBJECTIVE: Rwanda amended its abortions law in 2012 to allow for induced abortion under certain circumstances. We explore how Rwandan health care providers (HCP) understand the law and implement it in their clinical practice. DESIGN: Fifty-two HCPs involved in post-abortion care in Kigali were interviewed by qualitative individual in-depth interviews (n =32) and in focus group discussions (n =5) in year 2013, 2014, and 2016. All data were analyzed using thematic analysis. FINDINGS: HCPs express ambiguities on their rights and responsibilities when providing abortion care. A prominent finding was the uncertainties about the legal status of abortion, indicating that HCPs may rely on outdated regulations. A reluctance to be identified as an abortion provider was noticeable due to fear of occupational stigma. The dilemma of liability and litigation was present, and particularly care providers' legal responsibility on whether to report a woman who discloses an illegal abortion. CONCLUSION: The lack of professional consensus is creating barriers to the realization of safe abortion care within the legal framework, and challenge patients right for confidentiality. This bring consequences on girl's and women's reproductive health in the setting. IMPLICATIONS FOR PRACTICE: To implement the amended abortion law and to provide equitable maternal care, the clinical and ethical guidelines for HCPs need to be revisited.

Abortion and contraceptive use stigma: a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya.

Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use - the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13-21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = .003 and 50.6%, p = .007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p = .899) or contraceptive use stigma (p = .823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya.

Evaluating a model for the capacity building of midwifery eduators in Bangladesh through a blended, web-based master's programme.

Background: While setting international standards for midwifery education has attracted considerable global attention, the education and training of midwifery educators has been relatively neglected, particularly in low-resource settings where capacity building is crucial. Objective: The aim of this study was to describe the expectations of midwifery educators in Bangladesh who took part in a blended web-based master's programme in SRHR and the extent to which these were realized after 12 months of part-time study. Methods: Both quantitative and qualitative methods have been used to collect data. A structured baseline questionnaire was distributed to all participants at the start of the first course (n = 30) and a second endpoint questionnaire was distributed after they (n = 29) had completed the core courses one year later. At the start of the first course, five focus group discussions (FGD) were held with the midwifery educators. Descriptive statistics and content analysis were used for the analyses. Results: Midwifery educators who took part in the study identified expectations that can be grouped into three distinct areas. They hoped to become more familiar with technology, anticipated they would learn pedagogical and other skills that would enable them to better support their students' learning and thought they might acquire skills to empower their students as human beings. Participants reported they realized these ambitions, attributing the master's programme with helping them take responsibility for their own teaching and learning, showing them how to enhance their students' learning and how to foster reflective and critical thinking among them. Conclusions: Midwifery educators have taken part in a creative learning environment which has developed their engagement in teaching and learning. They have done this using a blended learning model which combines online learning with face-to-face contact. This model can be scaled up in low resource and remote settings.

Morality versus duty - A qualitative study exploring midwives' perspectives on post-abortion care in Uganda.

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.

Evaluating the safety, effectiveness and acceptability of treatment of incomplete second-trimester abortion using misoprostol provided by midwives compared with physicians: study protocol for a randomized controlled equivalence trial.

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.

Qualitative study showed that a culturally tailored parenting programme improved the confidence and skills of Somali immigrants.

AIM: Parenting programmes tailored to immigrant parents have been reported to improve the mental health of the children and parents, as well as parents' sense of competence in parenting. However, research on parents' experiences of programmes tailored to their needs is scarce. This qualitative study aimed to describe Somali parents' experiences of how a culturally sensitive programme affected their parenting. METHODS: The study was conducted in a middle-sized city in Sweden in 2015. Data were collected through semi-structured interviews with 50 participants two months after they took part in a parenting support programme. Inductive and deductive qualitative content analyses were used. RESULTS: A light has been shed was a metaphor that emerged from the analysis and that captured the knowledge the parents gained from the parenting system in Sweden. Parents gained confidence in their parenting role and became emotionally aware of their child's social and emotional needs and how to respond to them. Holding the sessions in the participant's native language was important for the parents' participation and acceptance of the programme. CONCLUSION: Parenting programmes should be tailored to the specific needs of the participants and cultural sensitivity should be factored into programmes to attract immigrant parents.

Contraceptive use among migrant, second-generation migrant and non-migrant women seeking abortion care: a descriptive cross-sectional study conducted in Sweden.

INTRODUCTION: The objective of this study was to compare ever-in life contraception use, use of contraception at current conception, and planned use of contraception after an induced abortion, among three groups of women: migrants, second-generation migrants and non-migrant women, and to compare the types of contraception methods used and intended for future use among the three groups of women. METHODS: The cross-sectional study administered a questionnaire face-to-face to women aged 18 years and older who were seeking abortion care at one of six abortion clinics in Stockholm County from January to April 2015. RESULTS: The analysis included 637 women. Migrants and second-generation migrants were less likely to have used contraception historically, at the time of the current conception, and to plan to use contraception after their induced abortion compared with non-migrant women. Historically, non-migrants had used pills (89%) and withdrawal (24%) while migrants had used the copper intrauterine device (24%) to a higher extent compared to the other two groups of women. Both the migrants (65%) and second-generation migrants (61%) were more likely than the non-migrants (48%) to be planning to use long-acting reversible contraception. CONCLUSIONS: Lower proportions of contraception use were found in migrants and second-generation migrants than in non-migrants. In addition, there were significant differences in the types of contraception methods used historically and intended for future use.