Misoprostol Treatment of Mid Trimester Incomplete Abortion by Midwives and Doctors in Uganda.

NCT ID: NCT03622073

Last Updated: 2022-03-11

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 1191 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2018-08-14
• Study Completion Date: 2021-12-16

Brief Summary

It is estimated that 47,000 women die every year due to consequences of unsafe abortion globally. The majority of pregnancy related deaths occur in low income countries where induced abortion is restricted, unmet need for contraception is high, and women's status is low. Uganda has a high total fertility rate of 5.4 children per woman, low contraceptive prevalence rate of 39%, and more than half of these pregnancies are unintended. Induced abortion is controversial and restricted in Uganda and legally permitted only to save a woman's life. As a result, women often resort to unsafe abortion- that's either performed by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards. Of the estimated 314,304 women who undergo unsafe abortions each year in Uganda, about 41% receive treatment for complications. This equates to an annual rate of 12 per 1,000 women aged 15-49 years being hospitalized for induced abortion complications, which is considered high in international comparison. In Uganda, outside the larger hospitals and private settings, access to safe post abortion care and surgical facilities are scarce. Studies have showed that trained midwives can deliver safe, effective and acceptable post abortion care using misoprostol in the first trimester. Currently in Uganda, treatment of second trimester incomplete abortion is restricted to physicians. This study will provide evidence on whether treatment for incomplete abortion using misoprostol by mid-level providers can be extended to the early second trimester period. The investigators hypothesize that misoprostol treatment for incomplete second trimester abortion provided by midwives is equivalent to that of physicians requiring no further surgical intervention. Women with incomplete abortion will be randomly allocated to undergo a clinical assessment and treatment with misoprostol either by physician or midwife with safety and effectiveness as main outcomes in the RCT carried out in hospital and high volume health centres in Central Uganda.

Detailed Description

This randomized controlled equivalence trial (RCT) implemented at eight hospitals and Health centres in Central Uganda will include 1192 eligible women with incomplete abortion of uterine size >12 weeks up to 18 weeks. Following informed consent, each participant will be randomly assigned to undergo a clinical assessment and treatment by either a midwife (intervention arm) or physician (control arm); receive 400mcg of misoprostol administered sublingually 3 hourly up to 5 doses within 24 hours at the health facility until a complete abortion is confirmed. Women who do not achieve a complete abortion within 24 hours will undergo a surgical method of uterine evacuation. Pre-discharge information on danger signs, contraceptive counselling and provision will be done with follow up 14 days later to assess secondary outcomes and acceptability. Analyses will be by Intention-to-Treat (ITT). Background characteristics and outcomes will be presented using descriptive statistics. Differences between groups will be analyzed using risk difference (95% CI) and equivalence established if it lies between the pre-defined range of -5% to +5%. Chi-square test will be used for comparison of outcome and t test used to compare mean values. P-values equal to or lower than 0.05 will be considered statistically significant.

Conditions

Incomplete Abortion

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: SINGLE

Study Groups

Misoprostol treatment by Midwife

Administration of misoprostol by the midwife and assessment for the primary outcome.

Group Type: EXPERIMENTAL

Misoprostol treatment by Midwife

Intervention Type: OTHER

Medical management of incomplete abortion

Misoprostol treatment by Doctor

Administration of misoprostol by the doctor and assessment for the primary outcome.

Group Type: ACTIVE_COMPARATOR

Misoprostol treatment by Doctor

Intervention Type: OTHER

Medical management of incomplete abortion

Interventions

Misoprostol treatment by Midwife

Medical management of incomplete abortion

Intervention Type: OTHER

Misoprostol treatment by Doctor

Medical management of incomplete abortion

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• Vaginal bleeding
• With or without contractions with a uterine size > 12 weeks to < 18 weeks
• History of partial expulsion
• Open cervical os.

Exclusion Criteria

• Known allergy to misoprostol,
• Unstable hemodynamic status (systolic blood pressure < 90mmHg) and shock
• Signs of pelvic infection and/or sepsis
• Previous caesarean delivery/uterine scar
• Suspected extra uterine pregnancy.

• Minimum Eligible Age: 15 Years
• Eligible Sex: FEMALE
• Accepts Healthy Volunteers: No

Sponsors

Karolinska Institutet

OTHER

Sponsor Role: collaborator

London School of Hygiene and Tropical Medicine

OTHER

Sponsor Role: collaborator

Makerere University

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Kristina G Danielsson, PhD

Role: PRINCIPAL_INVESTIGATOR

Karolinska Institutet

Josaphat Byamugisha, PhD

Role: PRINCIPAL_INVESTIGATOR

Makerere University

Susan Atuhairwe, MD

Role: PRINCIPAL_INVESTIGATOR

Makerere University

Locations

Entebbe Hospital

Entebbe, , Uganda

Gombe Hospital

Gombe, , Uganda

Kawempe Hospital

Kampala, , Uganda

Kayunga Hospital

Kayunga, , Uganda

Kawolo Hospital

Lugazi, , Uganda

Luwero HC IV

Luwero, , Uganda

Masaka Hospital

Masaka, , Uganda

Mityana Hospital

Mityana, , Uganda

Mpigi HC IV

Mpigi, , Uganda

Kiganda HC IV

Mubende, , Uganda

Mukono HC IV

Mukono, , Uganda

Nakaseke Hospital

Nakaseke, , Uganda

Kasangati HC IV

Wakiso, , Uganda

Wakiso HC IV

Wakiso, , Uganda

Countries

Uganda

References

Faundes A. Strategies for the prevention of unsafe abortion. Int J Gynaecol Obstet. 2012 Oct;119 Suppl 1:S68-71. doi: 10.1016/j.ijgo.2012.03.021. Epub 2012 Aug 9.

Reference Type: BACKGROUND

PMID: 22883917 (View on PubMed)

Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, Rossier C, Gerdts C, Tuncalp O, Johnson BR Jr, Johnston HB, Alkema L. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016 Jul 16;388(10041):258-67. doi: 10.1016/S0140-6736(16)30380-4. Epub 2016 May 11.

Reference Type: BACKGROUND

PMID: 27179755 (View on PubMed)

Uganda Bureau of Statistcs (UBOS) and ICF. 2017. Uganda Demographic and Health Survey 2016: Key Indicators Report. Kampala, Uganda: UBOS, and Rockville, Maryland, USA: UBOS and ICF.

Reference Type: BACKGROUND

Hussain R. Unintended pregnancy and abortion in Uganda. Issues Brief (Alan Guttmacher Inst). 2013 Jan;(2):1-8.

Reference Type: BACKGROUND

PMID: 23550324 (View on PubMed)

Prada E, Atuyambe LM, Blades NM, Bukenya JN, Orach CG, Bankole A. Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003. PLoS One. 2016 Nov 1;11(11):e0165812. doi: 10.1371/journal.pone.0165812. eCollection 2016.

Reference Type: BACKGROUND

PMID: 27802338 (View on PubMed)

Mark AG, Edelman A, Borgatta L. Second-trimester postabortion care for ruptured membranes, fetal demise, and incomplete abortion. Int J Gynaecol Obstet. 2015 May;129(2):98-103. doi: 10.1016/j.ijgo.2014.11.011. Epub 2015 Jan 19.

Reference Type: BACKGROUND

PMID: 25660084 (View on PubMed)

Klingberg-Allvin M, Cleeve A, Atuhairwe S, Tumwesigye NM, Faxelid E, Byamugisha J, Gemzell-Danielsson K. Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial. Lancet. 2015 Jun 13;385(9985):2392-8. doi: 10.1016/S0140-6736(14)61935-8. Epub 2015 Mar 27.

Reference Type: BACKGROUND

PMID: 25817472 (View on PubMed)

Cleeve A, Byamugisha J, Gemzell-Danielsson K, Mbona Tumwesigye N, Atuhairwe S, Faxelid E, Klingberg-Allvin M. Women's Acceptability of Misoprostol Treatment for Incomplete Abortion by Midwives and Physicians - Secondary Outcome Analysis from a Randomized Controlled Equivalence Trial at District Level in Uganda. PLoS One. 2016 Feb 12;11(2):e0149172. doi: 10.1371/journal.pone.0149172. eCollection 2016.

Reference Type: BACKGROUND

PMID: 26872219 (View on PubMed)

Moran M, Ortega J, Hodoglugil NN. Osur et al.'s Implementation of misoprostol for postabortion care in Kenya and Uganda: a qualitative evaluation. Glob Health Action. 2012 Jul 18;6:21786. doi: 10.3402/gha.v6i0.21786. No abstract available.

Reference Type: BACKGROUND

PMID: 23870184 (View on PubMed)

Pongsatha S, Tongsong T. Randomized controlled trial comparing efficacy between a vaginal misoprostol loading and non-loading dose regimen for second-trimester pregnancy termination. J Obstet Gynaecol Res. 2014 Jan;40(1):155-60. doi: 10.1111/jog.12147. Epub 2013 Sep 5.

Reference Type: BACKGROUND

PMID: 24033985 (View on PubMed)

Dawson AJ, Buchan J, Duffield C, Homer CS, Wijewardena K. Task shifting and sharing in maternal and reproductive health in low-income countries: a narrative synthesis of current evidence. Health Policy Plan. 2014 May;29(3):396-408. doi: 10.1093/heapol/czt026. Epub 2013 May 8.

Reference Type: BACKGROUND

PMID: 23656700 (View on PubMed)

Nabudere H, Asiimwe D, Mijumbi R. Task shifting in maternal and child health care: an evidence brief for Uganda. Int J Technol Assess Health Care. 2011 Apr;27(2):173-9. doi: 10.1017/S0266462311000055. Epub 2011 Mar 30.

Reference Type: BACKGROUND

PMID: 21450128 (View on PubMed)

Atuhairwe S, Hanson C, Atuyambe L, Byamugisha J, Tumwesigye NM, Ssenyonga R, Gemzell-Danielsson K. Evaluating women's acceptability of treatment of incomplete second trimester abortion using misoprostol provided by midwives compared with physicians: a mixed methods study. BMC Womens Health. 2022 Nov 5;22(1):434. doi: 10.1186/s12905-022-02027-y.

Reference Type: DERIVED

PMID: 36335344 (View on PubMed)

Atuhairwe S, Byamugisha J, Kakaire O, Hanson C, Cleeve A, Klingberg-Allvin M, Tumwesigye NM, Gemzell-Danielsson K. 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. Lancet Glob Health. 2022 Oct;10(10):e1505-e1513. doi: 10.1016/S2214-109X(22)00312-6. Epub 2022 Aug 26.

Reference Type: DERIVED

PMID: 36030801 (View on PubMed)

Atuhairwe S, Byamugisha J, Klingberg-Allvin M, Cleeve A, Hanson C, Tumwesigye NM, Kakaire O, Danielsson KG. 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. Trials. 2019 Jun 21;20(1):376. doi: 10.1186/s13063-019-3490-5.

Reference Type: DERIVED

PMID: 31227019 (View on PubMed)

Other Identifiers

REC REF 2017-016

Identifier Type: -

Identifier Source: org_study_id