Marijke Alblas


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    Comparison of the safety and satisfaction of first trimester abortions performed by
    physicians and mid-level providers using MVA in South Africa
    Marijke Alblas
    Hoffman M*, Harries J*, Morroni C*, Beksinka M**, Kunene B**, Warriner I.***
    * Women’s Health Research Unit, University of Cape Town, South Africa
    ** Reproductive Health Research and HIV Unit, Durban, South Africa
    *** World Health Organization, Geneva, Switzerland
    Background: In countries where legislation permits the termination of early pregnancy,
    limited resources, including available trained personnel, often restrict access to safe
    abortion services. In some countries in order to improve access, trained mid-level
    providers (nurses, midwives and physician assistants) perform first trimester abortions.
    This WHO collaborative study was conducted in South Africa and Vietnam to evaluate the
    safety and effectiveness of first trimester abortions performed by mid-level providers
    (MLPs) as compared to those performed by physicians. The South African component of
    the study will be presented.
    Methods: A randomised controlled equivalence trial was conducted between September
    2003 and June 2004 in four Marie Stopes International clinics in South Africa. All women
    seeking a first trimester abortion were invited to participate in the study. Eligibility criteria
    included: gestational age of no more than 12 weeks, age 18 years or above, and
    willingness to return for a follow-up visit, or to have a telephone, home or outside clinic
    interview. Women were randomly assigned to a mid-level provider or physician for the
    abortion and were followed-up by study staff 14 days later. The primary outcomes of
    interest were complications occurring within two weeks of the abortion procedure. These
    complications, immediate or delayed, were clinically verified. Patients’ satisfaction with the
    service was assessed.
    Results: Six physicians and six MPLs participated in the study. A total of 1160 women
    consented to participate, 581were randomised to a physician and 579 to a mid-level
    provider. Six women withdrew from the study and one was lost to follow up. There were
    no complications among the physicians and eight (seven retained products and one
    infection) among the mid-level providers. Measures of equivalence of complication rate 

    between providers was 1.4% (95% CI 0.4-2.7) This was well below the a priori margin of
    equivalence which was set at 4.8%. More than 96% of women reported satisfaction with
    quality of care.
    Conclusion: Overall the quality of care was excellent and there was no difference
    between physicians and mid-level providers. The complication rate was low and met the
    criteria for equivalence. Given appropriate training and in a supportive environment MLPs
    provide first trimester MVAs as safely as physicians.

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    The efficacy, safety and acceptability of medical and surgical second trimester

    termination of pregnancy in Cape Town, South Africa

    Marijke Alblas, Independent Consultant, South Africa

    Co-authors: Kelly Blanchard, Ibis Reproductive and Health SA, Debbie Constant, Women's Health Research Unit University of Cape Town, Daniel Grossman, Ibis Reproductive Health SA, Jane Harries,

    Women's Health Research Unit University of Cape Town, Naomi Lince, Ibis Reproductive Health SA

    To examine efficacy, safety and acceptability of two 2nd trimester abortion techniques used in South Africa: medical induction (MI) with misoprostol alone and dilation and evacuation (D&E).

    In February-July 2008, we enrolled 304 adult women undergoing abortion at 13-20 weeks at 5 hospitals around Cape Town in a cross-sectional, observational study. 220 underwent D&E with misoprostol cervical priming (up to 3 doses) and paracervical block, and 84 underwent MI. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.Data were analyzed using SPSS v14.

    Median age was 25 years, median parity 1, and median education grade 12. Median gestational age was different between D&E and MI clients (16.0 weeks vs. 18.1 weeks, p<0.001). D&E was more effective than MI (99.5% vs. 50.0% of cases completed on-site and without unplanned surgical procedure, p<0.001). Complications were common (43.8% D&E vs. 52.4% MI, p=0.2). Fetus was expelled prior to procedure in 43.3% of D&E cases. In addition to incomplete abortion, there were 3 MI cases with blood transfusion, 1 hemorrhage without transfusion and 1 fever. 98.8% MI and no D&E clients needed overnight stay. Most women were somewhat-very satisfied with their experience (95% D&E vs. 95.9% MI). More D&E clients compared to MI reported moderate-extreme physical pain (75.7% vs. 59.5%, p=0.007) and moderate-extreme emotional discomfort (49.8% vs. 33.8%, p=0.017).

    D&E was more effective, required shorter hospital stay and had fewer severe complications. Second trimester abortion services can be improved in South Africa by expanding D&E training, altering the cervical priming protocol for D&E, improving pain management, and introducing mifepristone.

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    Training midwives and doctors in post-termination
    of pregnancy care in Gabon and Cameroon
    Alblas, M; Ndembi, AP; Pheterson, G; Mbia, C;
    Mekui, JE
    Middle Africa Network for Women’s Reproductive Health: Gabon,
    Cameroon and Equatorial Guinea
    The NGO Middle Africa Network for Women’s Reproductive
    Health: Gabon, Cameroon and Equatorial Guinea – GCG is
    devoted to research, education and training to understand
    obstacles to better health care. This presentation focuses on one
    central part of the mission: training midwives and doctors in
    post-termination of pregnancy (TOP) care, mainly manual
    vacuum aspiration. After a needs assessment initial field trip in
    2009 it became clear that the morbidity and mortality among
    women due to unsafe TOP is high in rural areas in Northern
    Gabon, southern Cameroon and eastern Equatorial Guinea.
    When complications from back street TOP arise, women arrive
    late (or never) for emergency hospital care because they know
    TOP is illegal and highly stigmatised, and often they have no
    money either for transport to the hospital or for the medical aid
    they need. If a doctor is present, he/she can do a sharp curettage
    under general anesthesia, but this is expensive and in the more
    rural areas often there is no doctor. Pregnancy and birth are
    typically the domain of midwives, but they are not trained in
    treating TOP-related complications since procedures such as MVA
    or misoprostol use are not institutionally recognised, and only
    doctors perform D&Cs.
    Recently one of our trained midwives has been appointed by
    the Ministry of Health to train all the midwives in the country in
    post-TOP MVA. In the last 3 years this network has made a

    significant first step in demonstrating that also in a country where
    TOP is illegal, one can build capacity, mobilise attitude change
    and enlist institutional support.