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Pathways to seeking medication abortion care: A qualitative research in Uttar Pradesh, India.

ABSTRACT: INTRODUCTION:Abortion is legal in India and medication abortion (MA) using a combined regimen of mifepristone and misoprostol is the preferred method. Users increasingly purchase MA kits directly from pharmacies, in some cases experiencing perceived complications and approaching a facility for care. We present findings of a qualitative research tracing the decision-making pathway(s) of MA users in Uttar Pradesh, India, to help understand knowledge and behaviour gaps, and recommend ways to improve the overall quality of care at these service delivery points. METHODS:Forty in-depth interviews were conducted with recent MA users (20 each of clinic and pharmacy clients) across three districts. Providers were purposively selected in collaboration with an international organization selling MA kits, using their list of pharmacies and clinics. MA users were identified from the clients of the selected providers, and additionally through the snow ball method. Interviews were conducted in Hindi with verbal informed consent in a private place convenient to the respondent. Transcripts were translated to English and analysed thematically. RESULTS:Users first sought MA kits at pharmacies out of convenience, low cost and customer anonymity. Men often purchased kits for their partners and trusted the chemist for guidance on dosage, progression and side effects. For side effects or other concerns after using an MA kit, users first visited their neighbourhood doctor or traditional practitioner. These providers either attempted to treat the issue and failed, or directly advised her to consult a gynaecologist. The final point of care was gynaecologists, preferably female private practitioners with their own clinics. They diagnosed most abortion-related cases as incomplete abortions, emptying the uterus using the dilation and curettage method. Comparatively low cost and convenience made users inclined towards repeat use of MA. CONCLUSION:There are information gaps at various stages in the MA pathway that need to be addressed. Large scale public information programmes are required on safe abortion care- when is it legal, where to obtain MA, dosage, side effects and signs of possible complications. Pharmacists could be trained or incentivized to improve their quality of care to facilitate adequate exchange of information on MA. Since, for most couples, the male partner purchases MA, information approaches or tools are needed that pharmacists can give men to share directly with the MA user.

SUBMITTER: Srivastava A

PROVIDER: S-EPMC6513085 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Project description:BackgroundAlmost 3 quarters of India's roughly 16 million annual abortions are done through medication abortion purchased from pharmacists outside of healthcare facilities. The quality of information provided by pharmacists about medication abortion is often poor.ObjectiveTo determine whether pharmacists selling medication abortion provide different information or ask different, potentially stigmatizing questions to clients by gender and marital status.Study designMystery clients presenting as 4 profiles (unmarried woman, unmarried man, married woman, and married man) purchasing medication abortion interacted with 111 pharmacists in 3 districts around Lucknow, Uttar Pradesh in 2018. Data were collected immediately after the interaction. The differences in the information conveyed and the questions asked by the pharmacists by mystery client characteristics were analyzed using logistic regression in Stata 15 MP.ResultsPharmacists very rarely asked intrusive, medically irrelevant questions and appeared willing to sell medication abortion to all the mystery clients regardless of gender, age, or marital status. However, the pharmacists were overall less likely to provide the female mystery clients with as comprehensive and correct information on medication abortion as they were to male mystery clients, particularly if female mystery clients presented as unmarried.ConclusionPharmacists are observed to provide differential and poorer quality information about medication abortion to women, especially if they seem unmarried, potentially putting women at risk of having a lower-quality and less supported experience of using the medication. However, the pharmacists' willingness to sell the medication to all mystery clients and the lack of intrusive questions and comments reinforces out-of-facility medication abortion as a way for individuals to access an often-stigmatized service. Interventions must find a way to either address this bias among pharmacists, or more practically, to provide high-quality information directly to the individuals seeking medication abortion.

Project description:BACKGROUND:The use of medication abortion is increasing rapidly in India, the majority of which is purchased through pharmacies. More information is needed about the quality of services provided by pharmacist about medication abortion, especially barriers to providing high quality information. The goal of this study was to explore the quality of pharmacist medication abortion provision using mixed methods to inform the developed of an intervention for this population. METHODS:Data was collected via convenience sampling using three methods: a quantitative survey of pharmacists (N?=?283), mystery clients (N?=?111), and in-depth qualitative interviews with pharmacist (N?=?11). Quality indictors from the quantitative data from surveys and mystery clients were compared. Qualitative interviews were used to elucidate reasons behind findings from the quantitative survey. RESULTS:Quality of information provided to client purchasing medication abortion was low, especially related to timing and dosing of misoprostol (18% of pharmacists knew correct timing) and side effects (31% not telling any information on side effects). Mystery clients reported lower quality (less correct information) than pharmacists reported about their own behaviors. Qualitative interviews suggested that many barriers exist for pharmacists, including perceptions about what information clients can understand and desire, and also lack of comfort giving certain information to certain types of clients (young women). CONCLUSIONS:It is essential to improve the quality of information given to client purchasing medication abortion from pharmacists. Our findings highlight specific gaps in knowledge and reasons for poor quality information. Differences in guidelines available at that time from the Indian Government, World Health Organization, and the medication abortion boxes may lead to confusion amongst pharmacists and potentially clients. Interventions need to improve both knowledge about medication abortion and also biases in the provision of care.

Project description:BackgroundImproving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality.MethodsNine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women's experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages-admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care.ResultsAdmission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care 'structure' and 'process'. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments.ConclusionsThe study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.

Project description:BackgroundPersistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions.ObjectiveThis study aimed to examine pregnant women's expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider's perceptions of the same, as well as the barriers that limit their ability to provide high-quality care.MethodsA qualitative descriptive analysis was conducted on data from two studies - focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women's experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016-17) to understand provision of person-centred care. Provider perspectives were matched with themes of women's perspectives on quality of childbirth care in facilities.ResultsMajor themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries.ConclusionsThis study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers' perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.

Project description:BackgroundGynaecological morbidities are more common than reproductive and contraceptive morbidities and constitute a substantial proportion of disease burden in women. This study aimed to examine the prevalence and factors associated with gynaecological morbidities and the treatment-seeking behaviour among adolescent girls residing in Bihar and Uttar Pradesh, India.MethodologyThe study utilized data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey with a sample size of 14,625 adolescents girls aged 10-19 years. We defined gynaecological morbidity in dichotomous form, created from five questions on different morbidities. Further, the treatment-seeking behaviour was assessed for reported gynaecological morbidities three months prior to the survey. Univariate and bivariate analysis was used to perform analysis to carve out the preliminary results. Additionally, the study employed the heckprobit selection model, a two-equation model, to identify the determinants of outcome variables.ResultsOverall, about one-fourth (23.6%) of the adolescent girls reported suffering from gynaecological morbidities, and only one-third of them went for treatment. Non-Scheduled Caste/Scheduled Tribe (Non-SC/ST) adolescents were significantly less likely to have gynaecological morbidities (β: -0.12; CI: -0.18, -0.06) compared to SC/ST counterparts; however, they were more likely to go for the treatment (β: 0.09; CI: 0.00, 0.19). The adolescents who had 8-9 (β: 0.17; CI: 0.05, 0.29) or ten and above years of education (β: 0.21; CI: 0.09, 0.34) had a higher likelihood of going for the treatment than adolescents with no education. Moreover, adolescents who belonged to rural areas were less likely to go for the treatment of gynaecological morbidities (β: -0.09; CI: -0.17, -0.01) than urban counterparts.ConclusionMulti-pronged interventions are the need of the hour to raise awareness about the healthcare-seeking behaviour for gynaecological morbidities, especially in rural areas. Adolescent girls shall be prioritized as they may lack the knowledge for gynaecological morbidities, and such morbidities may go unnoticed for years. Mobile clinics may be used to disseminate appropriate knowledge among adolescents and screen asymptomatic adolescents for any possible gynaecological morbidity.

Project description:This paper explores the multilevel factors associated with maternal health utilization in India's most populous state, Uttar Pradesh. 3 key utilization practices: registration of pregnancy, receipt of antenatal care, and delivery at home are examined for district and individual level predictors. The data is based on 5666 household surveys conducted as part of a baseline evaluation of the Uttar Pradesh Technical Support Unit (UPTSU.) program.This intervention aims to assist the Government of Uttar Pradesh in increasing the efficiency, effectiveness, and equity of service delivery across a continuum of reproductive, maternal, new-born, child, and adolescent health (RMNCH+A) outcomes.The paper employs multilevel models that control for individuals being nested within districts in order to understand the predictors of maternal health care utilization.The study identifies several individual-level predictors of health care utilization, including: literacy of the woman, the husband's schooling, age at marriage, and socio-economic factors. Key predictors of pregnancy registration include husband's schooling (OR 1.49, 95% CI 1.26-1.76), having a bank account (OR 1.36, 95% CI 1.11-1.68), and owning a house (OR 2.28, 95% CI 1.85-2.80). Factors affecting antenatal care include the woman's literacy (OR 1.49, 95% CI 1.28-1.73), the respondent having had a job in the last year (OR 1.39, 95% CI 1.10-1.77), and owning a house (OR 2.83, 95% CI 2.27-3.53). Home delivery tends to be associated with woman's literacy (OR 0.62, 95% CI 0.54-0.72) and marriage age of 15 and younger (OR 1.48, 95% CI 1.26-1.73).Interventions having equity considerations need to disrupt existing patterns of the health gradient. Successful implementation of such interventions, necessitate understanding the mechanisms that can disrupt the unequal utilization patterns and target domains of disadvantage. Knowledge of key predictors of utilization can aid in the implementation of such complex interventions.

Project description:BackgroundThe sustainable development goals (SDG) aim at satisfying three-fourths of family planning needs through modern contraceptive methods by 2030. However, the traditional methods (TM) of family planning use are on the rise, along with modern contraception in Uttar Pradesh (UP), the most populous Indian state. This study attempts to explore the dynamics of rising TM use in the state.MethodsWe used a state representative cross-sectional survey conducted among 12,200 Currently Married Women (CMW) aged 15-49 years during December 2020-February 2021 in UP. Using a multistage sampling technique, 508 primary sampling units (PSU) were selected. These PSU were ASHA areas in rural settings and Census Enumeration Blocks in urban settings. About 27 households from each PSU were randomly selected. All the eligible women within the selected households were interviewed. The survey also included the nearest public health facilities to understand the availability of family planning methods. Univariate and bivariate analyses were conducted. Appropriate sampling weights were applied.ResultsOverall, 33.9% of CMW were using any modern methods and 23.7% any TM (Rhythm and withdrawal) at the time of survey. The results show that while the modern method use has increased by 2.2 percentage points, the TM use increased by 9.9 percentage points compared to NFHS-4 (2015-16). The use of TM was almost same across women of different socio-demographic characteristics. Of 2921 current TM users, 80.7% started with TM and 78.3% expressed to continue with the same in future. No side effects (56.9%), easy to use (41.7%) and no cost incurred (38.0%) were the main reasons for the continuation of TM. TM use increased despite a significant increase (66.1 to 81.3%) in the availability of modern reversible methods and consistent availability of limiting methods (84.0%) in the nearest public health facilities.ConclusionInitial contraceptive method was found to have significant implications for current contraceptive method choice and future preferences. Program should reach young and zero-parity women with modern method choices by leveraging front-line workers in rural UP. Community and facility platforms can also be engaged in providing modern method choices to women of other parities to increase modern contraceptive use further to achieve the SDG goals.

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Pathways to seeking medication abortion care: A qualitative research in Uttar Pradesh, India.

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