- Email: [email protected]
I385 WHY MISOPROSTOL MATTERS
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
taken by the provider(s) in admissions, delivery room and postnatal ward; 677 observations were recorded from 13 health facilities in 2011. Analysis entailed cross-tabulations with Chi-square tests to determine differences in indices between sites. Constructs were developed to measure different types of abuse using Cronbach’s a (alpha) tests for internal consistency of the items of the construct. Results: Two thirds of the observations took place during the day and a third at night. Manifestations of disrespect and abuse were evident: un-dignified care (6%) aggression of any kind during labour (12.9%); such as – “you are stupid what are you doing” or being slapped by the provider; non-consented care – includes failure of provider to ask women permission to carry out a vaginal examination (54%). Some women had a perineal tear (30%) or episiotomy (14.5%) for repair. Only 25% were given a local anesthetic before the repair even though lignocaine was available in 86% of observations. Only 23% women were checked for amount of vaginal bleeding post delivery. Conclusion: Women suffer some form of abusive and disrespectful care during childbirth. Further investigation is required to examine the drivers of this behaviour. I384 COMMUNITY-BASED USE OF MISOPROSTOL FOR PPH PREVENTION: SNAPSHOT FROM A PILOT STUDY IN UGANDA DOCUMENTING SELF-ADMINISTRATION OF MISOPROSTOL IN A HOME DELIVERY SETTING A. Weeks. University of Liverpool, UK Previous studies have demonstrated the efficacy of misoprostol for the prevention and treatment of PPH when delivered by health care workers. Based on this, many programmes are starting to give misoprostol to women so that they can self-administer the drug immediately after delivery even if there is no health worker present. This would be especially important in settings like Uganda where over 90 per cent attend for antenatal care but over 50 per cent deliver at home without a skilled birth attendant. But the strategy has never been subjected to a randomised trial. A pilot randomised trial is in progress in four antenatal clinics in rural Mbale, Uganda. Unselected, consenting women of over 34 weeks’ gestation are randomised to receive misoprostol 600 mcg or placebo. Both groups receive counselling about the safe and effective use of misoprostol, along with a pictorial instruction leaflet. This is placed in a small neck purse and carried with the women so that the misoprostol is available to them even if they deliver when away from home. Village health workers monitor the women and contact the research team upon delivery so that they can be visited at home. The clinical outcomes include the decrease in haemoglobin from recruitment to delivery, adverse outcomes for mother and baby, and overall health status at 3–5 days. Other outcomes include loss to follow-up and acceptability of the protocol to women. The study will conclude in September 2012 and the results will be presented. I385 WHY MISOPROSTOL MATTERS B. Winikoff. Gynuity Health Projects, New York, NY, United States At this point in history, discussion of misoprostol is unavoidable in any consideration of improving women’s reproductive health. Misoprostol is an old medicine, originally registered and marketed for non-reproductive health purposes. Only gradually, based on the work of independent investigators and free-spirited innovators, was serious attention focused on its vital role in global reproductive health efforts. Misoprostol is a uniquely “forgiving” technology, well-adapted to various economic, technological, cultural and geographic environments. What do we mean by calling a technology “forgiving”? In essence, the possibilities for use are broad, the restrictions are few, the safety margin is wide, and the item is easily provided and affordable. Misoprostol has several important indications related to the most frequent causes of maternal death. As a
S257
small pill, it is easy transport and to store, and it is not sensitive to temperature. Wide dosage ranges are safe and effective. The product is inexpensive and easy to use at all levels of health care. Yet, as simple and powerful a technology as it is, misoprostol is not a panacea. Advocacy for its use has created backlash in some situations, and it faces both political and commercial hurdles in certain environments. We do not know how much its use can contribute to reduction of maternal mortality. We do know that it cannot substitute for well-designed and delivered services or for compassion and commitment of health care providers. For all this complexity, misoprostol presents us with an opportunity that is too important to ignore. I386 THE ROLE OF HOSPITAL VISITATION AND ACCREDITATION J. Wladimiroff Auditing or visiting of local Ob/Gyn training programmes has been a focus of attention resulting in a blueprint for a Hospital Visiting (Auditing) system for the quality assessment of specialist and subspecialist training across the EU. The programme has so far been based on voluntary applications. The main focus of the one day visit to a training unit is its training programme assuring the presence of a dedicated teaching staff, a competence-based curriculum, adequate clinical experience and a robust system for assessing a trainee’s progress. The EBCOG Visiting team consists of two senior gynaecologists and one trainee representing ENTOG. Similar to the EBCOG “Training the Trainers” courses, EBCOG has initiated “Training the Visitors” courses to create a pool of visitors for future audits. More than 110 visits have been conducted by EBCOG for general Ob/Gyn training programmes across the EU. A further 40 visits have been carried-out by the four European scientific subspecialty Societies ESGO, ESHRE, EAPM and EUGA together with EBCOG. A national Visiting and Accreditation system is now in place following a series of EBCOG visits in Norway, Finland, France and Portugal. EBCOG and national societies may jointly pave the way towards the introduction of more nationally based hospital visiting systems in the near future. I387 ETHIOPIA’S EXPERIENCE IN REDUCING MORBIDITY THROUGH SECOND TRIMESTER MEDICAL ABORTION SERVICES M.A. Woldetsadik. Obstetrics and Gynecology, University of Gondar School of Medicine, Ethiopia In Ethiopia, termination of pregnancy is allowed up to 28 weeks for reasons of rape/incest, fetal anomaly, physical or mental deficiency of the woman, including being a minor, or endangerment of the life or health of the woman. The proportion of women seeking second trimester services in Ethiopia, 20–40%, appears to be higher than other countries. In an effort to improve second trimester abortion services by increasing use of evidence-based medical abortion protocols, interventions were undertaken consisting of national and hospital-based assessments, values clarification workshops, training, and follow-up. Gondar University Hospital, in northern Ethiopia, was one of the initial sites chosen for this intervention due to its high abortion caseload, experienced providers, and adequate facilities. Prior to the intervention, approximately 50% of the second trimester cases were for post-abortion care (PAC). Since the training in October 2011, 365 women have received care. Introduction of second trimester medical services with a highly effective regimen of mifepristone and misoprostol has been safe even without the availability of dilation and evacuation. In addition, the emphasis on whole site values clarification training (from security guards to administrators) helped to allay fears and concerns regarding the expansion of abortion services in the second trimester and assisted in the creation of a supportive environment. This program in Ethiopia shows that quality second-trimester services can be achieved in a low-resource setting.
taken by the provider(s) in admissions, delivery room and postnatal ward; 677 observations were recorded from 13 health facilities in 2011. Analysis entailed cross-tabulations with Chi-square tests to determine differences in indices between sites. Constructs were developed to measure different types of abuse using Cronbach’s a (alpha) tests for internal consistency of the items of the construct. Results: Two thirds of the observations took place during the day and a third at night. Manifestations of disrespect and abuse were evident: un-dignified care (6%) aggression of any kind during labour (12.9%); such as – “you are stupid what are you doing” or being slapped by the provider; non-consented care – includes failure of provider to ask women permission to carry out a vaginal examination (54%). Some women had a perineal tear (30%) or episiotomy (14.5%) for repair. Only 25% were given a local anesthetic before the repair even though lignocaine was available in 86% of observations. Only 23% women were checked for amount of vaginal bleeding post delivery. Conclusion: Women suffer some form of abusive and disrespectful care during childbirth. Further investigation is required to examine the drivers of this behaviour. I384 COMMUNITY-BASED USE OF MISOPROSTOL FOR PPH PREVENTION: SNAPSHOT FROM A PILOT STUDY IN UGANDA DOCUMENTING SELF-ADMINISTRATION OF MISOPROSTOL IN A HOME DELIVERY SETTING A. Weeks. University of Liverpool, UK Previous studies have demonstrated the efficacy of misoprostol for the prevention and treatment of PPH when delivered by health care workers. Based on this, many programmes are starting to give misoprostol to women so that they can self-administer the drug immediately after delivery even if there is no health worker present. This would be especially important in settings like Uganda where over 90 per cent attend for antenatal care but over 50 per cent deliver at home without a skilled birth attendant. But the strategy has never been subjected to a randomised trial. A pilot randomised trial is in progress in four antenatal clinics in rural Mbale, Uganda. Unselected, consenting women of over 34 weeks’ gestation are randomised to receive misoprostol 600 mcg or placebo. Both groups receive counselling about the safe and effective use of misoprostol, along with a pictorial instruction leaflet. This is placed in a small neck purse and carried with the women so that the misoprostol is available to them even if they deliver when away from home. Village health workers monitor the women and contact the research team upon delivery so that they can be visited at home. The clinical outcomes include the decrease in haemoglobin from recruitment to delivery, adverse outcomes for mother and baby, and overall health status at 3–5 days. Other outcomes include loss to follow-up and acceptability of the protocol to women. The study will conclude in September 2012 and the results will be presented. I385 WHY MISOPROSTOL MATTERS B. Winikoff. Gynuity Health Projects, New York, NY, United States At this point in history, discussion of misoprostol is unavoidable in any consideration of improving women’s reproductive health. Misoprostol is an old medicine, originally registered and marketed for non-reproductive health purposes. Only gradually, based on the work of independent investigators and free-spirited innovators, was serious attention focused on its vital role in global reproductive health efforts. Misoprostol is a uniquely “forgiving” technology, well-adapted to various economic, technological, cultural and geographic environments. What do we mean by calling a technology “forgiving”? In essence, the possibilities for use are broad, the restrictions are few, the safety margin is wide, and the item is easily provided and affordable. Misoprostol has several important indications related to the most frequent causes of maternal death. As a
S257
small pill, it is easy transport and to store, and it is not sensitive to temperature. Wide dosage ranges are safe and effective. The product is inexpensive and easy to use at all levels of health care. Yet, as simple and powerful a technology as it is, misoprostol is not a panacea. Advocacy for its use has created backlash in some situations, and it faces both political and commercial hurdles in certain environments. We do not know how much its use can contribute to reduction of maternal mortality. We do know that it cannot substitute for well-designed and delivered services or for compassion and commitment of health care providers. For all this complexity, misoprostol presents us with an opportunity that is too important to ignore. I386 THE ROLE OF HOSPITAL VISITATION AND ACCREDITATION J. Wladimiroff Auditing or visiting of local Ob/Gyn training programmes has been a focus of attention resulting in a blueprint for a Hospital Visiting (Auditing) system for the quality assessment of specialist and subspecialist training across the EU. The programme has so far been based on voluntary applications. The main focus of the one day visit to a training unit is its training programme assuring the presence of a dedicated teaching staff, a competence-based curriculum, adequate clinical experience and a robust system for assessing a trainee’s progress. The EBCOG Visiting team consists of two senior gynaecologists and one trainee representing ENTOG. Similar to the EBCOG “Training the Trainers” courses, EBCOG has initiated “Training the Visitors” courses to create a pool of visitors for future audits. More than 110 visits have been conducted by EBCOG for general Ob/Gyn training programmes across the EU. A further 40 visits have been carried-out by the four European scientific subspecialty Societies ESGO, ESHRE, EAPM and EUGA together with EBCOG. A national Visiting and Accreditation system is now in place following a series of EBCOG visits in Norway, Finland, France and Portugal. EBCOG and national societies may jointly pave the way towards the introduction of more nationally based hospital visiting systems in the near future. I387 ETHIOPIA’S EXPERIENCE IN REDUCING MORBIDITY THROUGH SECOND TRIMESTER MEDICAL ABORTION SERVICES M.A. Woldetsadik. Obstetrics and Gynecology, University of Gondar School of Medicine, Ethiopia In Ethiopia, termination of pregnancy is allowed up to 28 weeks for reasons of rape/incest, fetal anomaly, physical or mental deficiency of the woman, including being a minor, or endangerment of the life or health of the woman. The proportion of women seeking second trimester services in Ethiopia, 20–40%, appears to be higher than other countries. In an effort to improve second trimester abortion services by increasing use of evidence-based medical abortion protocols, interventions were undertaken consisting of national and hospital-based assessments, values clarification workshops, training, and follow-up. Gondar University Hospital, in northern Ethiopia, was one of the initial sites chosen for this intervention due to its high abortion caseload, experienced providers, and adequate facilities. Prior to the intervention, approximately 50% of the second trimester cases were for post-abortion care (PAC). Since the training in October 2011, 365 women have received care. Introduction of second trimester medical services with a highly effective regimen of mifepristone and misoprostol has been safe even without the availability of dilation and evacuation. In addition, the emphasis on whole site values clarification training (from security guards to administrators) helped to allay fears and concerns regarding the expansion of abortion services in the second trimester and assisted in the creation of a supportive environment. This program in Ethiopia shows that quality second-trimester services can be achieved in a low-resource setting.