Post-abortion care with misoprostol – equally effective, safe and accepted when administered by midwives compared to physicians: a randomised controlled equivalence trial in a low-resource setting in Kenya

• Published in: BMJ open Vol. 7; no. 10; p. e016157
• Main Authors: Makenzius, Marlene, Oguttu, Monica, Klingberg-Allvin, Marie, Gemzell-Danielsson, Kristina, Odero, Theresa M A, Faxelid, Elisabeth
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 2017; BMJ Publishing Group
• Subjects: Abortifacient Agents, Nonsteroidal - therapeutic use; Abortion; Abortion, Incomplete; Abortion, Induced; Adult; Birth control; Community Gynaecology; Evidence-based medicine; Family planning; Female; Global Health; Health and Welfare; Health Policy; Health Resources; Humans; Hälsa och välfärd; Kenya; Male; Maternal Medicine; Maternal mortality; Medicin och hälsovetenskap; Middle Aged; Midwifery; Misoprostol - therapeutic use; Nurse Midwives; Outcome Assessment (Health Care); Patient Safety; Patient Satisfaction; Physicians; Pregnancy; Pregnancy Trimester, First; Public health; Reproductive Health Services - standards; Reproductive Medicine; Womens health; Workforce; Kenya; Uganda; Africa; Health Policy; Community Gynaecology; Maternal Medicine; Reproductive Medicine
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2017-016157

ObjectiveTo assess the effectiveness of midwives administering misoprostol to women with incomplete abortion seeking post-abortion care (PAC), compared with physicians.DesignA multicentre randomised controlled equivalence trial. The study was not masked.SettingsGynaecological departments in two hospitals in a low-resource setting, Kenya.PopulationWomen (n=1094) with incomplete abortion in the first trimester, seeking PAC between 1 June 2013 to 31 May 2016. Participants were randomly assigned to receive treatment from midwives or physicians. 409 and 401 women in the midwife and physician groups, respectively, were included in the per-protocol analysis.Interventions600 µg misoprostol orally, and contraceptive counselling by a physician or midwife.Main outcome measuresComplete abortion not needing surgical intervention within 7–10 days. The main outcome was analysed on the per-protocol population with a generalised estimating equation model. The predefined equivalence range was –4% to 4%. Secondary outcomes were analysed descriptively.ResultsThe proportion of complete abortion was 94.8% (768/810): 390 (95.4%) in the midwife group and 378 (94.3%) in the physician group. The proportion of incomplete abortion was 5.2% (42/810), similarly distributed between midwives and physicians. The model-based risk difference for midwives versus physicians was 1.0% (–4.1 to 2.2). Most women felt safe (97%; 779/799), and 93% (748/801) perceived the treatment as expected/easier than expected. After contraceptive counselling the uptake of a contraceptive method after 7–10 days occurred in 76% (613/810). No serious adverse events were recorded.ConclusionsTreatment of incomplete abortion with misoprostol provided by midwives is equally effective, safe and accepted by women as when administered by physicians in a low-resource setting. Systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception.Trial registration numberNCT01865136; Results.