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Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting.

ABSTRACT: Complications following spontaneous or induced abortion are a major cause of maternal morbidity. To manage these complications, post-abortion care (PAC) services should be readily available and easy to access. Standard PAC treatment includes surgical interventions that are highly effective but require surgical providers and medical centers that have the necessary space and equipment. Misoprostol has been shown to be an effective alternative to surgical evacuation and can be offered by lower level clinicians. This study sought to assess whether 400 mcg sublingual misoprostol could effectively evacuate the uterus after incomplete abortion and to confirm its applicability for use at lower level settings.All women presenting with incomplete abortion at one of three hospitals in Vietnam were enrolled. Providers were not asked to record if the abortion was spontaneous or induced. It is likely that all were spontaneous given the legal status and easy access to abortion services in Vietnam. Participants were given 400 mcg sublingual misoprostol and instructed to hold the pills under their tongue for 30 minutes and then swallow any remaining fragments. They were then asked to return one week later to confirm their clinical status. Study clinicians were instructed to confirm a complete expulsion clinically. All women were asked to complete a questionnaire regarding satisfaction with the treatment.Three hundred and two women were enrolled between September 2009 and May 2010. Almost all participants (96.3%) had successful completions using a single dose of 400 mcg misoprostol. The majority of women (87.2%) found the side effects to be tolerable or easily tolerable. Most women (84.3%) were satisfied or very satisfied with the treatment they received; only one was dissatisfied (0.3%). Nine out of ten women would select this method again and recommend it to a friend (91.0% and 90.0%, respectively).This study confirms that 400 mcg sublingual misoprostol effectively evacuates the uterus for most women experiencing incomplete abortion. The high levels of satisfaction and side effect tolerability also attest to the ease of use of this method. From these data and given the international consensus around the effectiveness of misoprostol for incomplete abortion care, it seems timely that use of the drug for this indication be widely expanded both throughout Vietnam and wherever access to abortion care is limited.ClinicalTrials.gov, NCT00670761.

SUBMITTER: Ngoc NT

PROVIDER: S-EPMC3704810 | biostudies-literature | 2013 May

REPOSITORIES: biostudies-literature

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Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting.

Ngoc Nguyen Thi Nhu NT Shochet Tara T Blum Jennifer J Hai Pham Thanh PT Dung Duong Lan DL Nhan Tran Thanh TT Winikoff Beverly B

BMC pregnancy and childbirth 20130522

<h4>Background</h4>Complications following spontaneous or induced abortion are a major cause of maternal morbidity. To manage these complications, post-abortion care (PAC) services should be readily available and easy to access. Standard PAC treatment includes surgical interventions that are highly effective but require surgical providers and medical centers that have the necessary space and equipment. Misoprostol has been shown to be an effective alternative to surgical evacuation and can be of ...[more]

PMID: 23697561

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Project description:In low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC) services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful.A total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation.Both misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%). Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92). Both tolerability of side effects and women's satisfaction were similar in the two study arms.Misoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability.This study has been registered at clinicaltrials.gov as NCT00466999 and NCT01539408.

Project description:BackgroundNursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues.Aims and objectivesWe aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses' work to others.MethodsThis paper is based on an 18-month qualitative study of three newborn units of three public hospitals-all located in Nairobi county-using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h' observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff.ResultsTo cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of 'subconscious triage'. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system.ConclusionOur findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of 'subconscious triage'. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.

Project description:Active management of the third stage of labor (AMTSL) describes interventions with the common goal to prevent postpartum hemorrhage (PPH). In low- and middle-income countries, implementation of AMTSL is hampered by shortage of skilled birth attendants and a high percentage of home deliveries. Task shifting of specific AMTSL components to unskilled birth attendants or self-administration could be a strategy to increase access to potentially life-saving interventions. This study was designed to evaluate the effect, acceptance and safety of task shifting of specific aspects of AMTSL to unskilled birth attendants.A systematic search was conducted in five databases in September 2015 to identify intervention studies of AMTSL implemented by unskilled birth attendants or pregnant women themselves. Quality of studies was evaluated with an adapted Cochrane Collaboration assessment tool.Of 2469 studies screened, 21 were included. All studies assessed implementation of uterotonics (misoprostol tablets or oxytocin injections), administered by community health workers (CHWs), auxiliary midwives, traditional birth attendants (TBAs) or self-administration at antenatal (home) visits or delivery. Task shifting for none of the other AMTSL components was reported. Task shifting of provision of uterotonics reduced the risk of PPH (RR 0.16 to 1) compared to standard care (13 studies, n?=?15.197). The correct dose and timing was reported for 83.4 to 99.8% (5 studies, n?=?6083) and 63 to 100% (9 studies, n?=?8378) women respectively. Uterotonics were recommended to others by 80 to 99.7% (7 studies, n?=?6445); 80 to 99.4% (5 studies, n?=?2677) would use the drug at next delivery. Willingness to pay for uterotonics varied from 54.6 to 100% (7 studies, n?=?6090).Task shifting of AMTSL has thus far been evaluated for administration of uterotonics (misoprostol tablets and oxytocin injected by CHWs and auxiliary midwives) and resulted in reduction of PPH, high rates of appropriate use and satisfaction among users. In order to increase AMTSL coverage in low-staffed health facilities, task shifting of uterine massage or postpartum tonus assessment to unskilled attendants or delivered women could be considered. Task shifting of controlled cord traction is currently not recommended.

Project description:BackgroundA 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.MethodsA 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.DiscussionOur 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 registrationClinicalTrials.gov, NCT03622073 . Registered on 9 August 2018.

Project description:BackgroundOne potential solution to limited healthcare access in low and middle income countries (LMIC) is task-shifting- the training of non-physician healthcare workers (NPHWs) to perform tasks traditionally undertaken by physicians. The aim of this paper is to conduct a systematic review of studies involving task-shifting for the management of non-communicable disease (NCD) in LMIC.MethodsA search strategy with the following terms "task-shifting", "non-physician healthcare workers", "community healthcare worker", "hypertension", "diabetes", "cardiovascular disease", "mental health", "depression", "chronic obstructive pulmonary disease", "respiratory disease", "cancer" was conducted using Medline via Pubmed and the Cochrane library. Two reviewers independently reviewed the databases and extracted the data.FindingsOur search generated 7176 articles of which 22 were included in the review. Seven studies were randomised controlled trials and 15 were observational studies. Tasks performed by NPHWs included screening for NCDs and providing primary health care. The majority of studies showed improved health outcomes when compared with usual healthcare, including reductions in blood pressure, increased uptake of medications and lower depression scores. Factors such as training of NPHWs, provision of algorithms and protocols for screening, treatment and drug titration were the main enablers of the task-shifting intervention. The main barriers identified were restrictions on prescribing medications and availability of medicines. Only two studies described cost-effective analyses, both of which demonstrated that task-shifting was cost-effective.ConclusionsTask-shifting from physicians to NPHWs, if accompanied by health system re-structuring is a potentially effective and affordable strategy for improving access to healthcare for NCDs. Since the majority of study designs reviewed were of inadequate quality, future research methods should include robust evaluations of such strategies.

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Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting.

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Results from a study using misoprostol for management of incomplete abortion in Vietnamese hospitals: implications for task shifting.

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