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  • 51.
    Osman, Fatumo
    et al.
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Flacking, Renée
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Schön, Ulla-Karin
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Socialt arbete.
    Parenthood in transition: Somali-born parents' experiences of and needs for parenting support programmes2016Inngår i: BMC International Health and Human Rights, ISSN 1472-698X, E-ISSN 1472-698X, Vol. 16, nr 1, artikkel-id 82Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Pre- and post-migration trauma due to forced migration may impact negatively on parents' ability to care for their children. Little qualitative work has examined Somali-born refugees' experiences. The aim of this study is to explore Somali-born refugees' experiences and challenges of being parents in Sweden, and the support they need in their parenting.

    METHODS: A qualitative descriptive study was undertaken. Data were collected from four focus group discussions (FGDs) among 23 Somali-born mothers and fathers living in a county in central Sweden. Qualitative content analysis has been applied.

    RESULTS: A main category, Parenthood in Transition, emerged as a description of a process of parenthood in transition. Two generic categories were identified: Challenges, and Improved parenting. Challenges emerged from leaving the home country and being new and feeling alienated in the new country. In Improved parenting, an awareness of opportunities in the new country and ways to improve their parenting was described, which includes how to improve their communication and relationship with their children. The parents described a need for information on how to culturally adapt their parenting and obtain support from the authorities.

    CONCLUSIONS: Parents experienced a process of parenthood in transition. They were looking to the future and for ways to improve their parenting. Schools and social services can overcome barriers that prevent lack of knowledge about the new country's systems related to parenthood. Leaving the home country often means separation from the family and losing the social network. We suggest that staff in schools and social services offer parent training classes for these parents throughout their children's childhood, with benefits for the child and family.

  • 52.
    Osman, Fatumo
    et al.
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Salari, Raziye
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Schön, Ulla-Karin
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Socialt arbete.
    Flacking, Renée
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Effects of a culturally tailored parenting support programme in Somali-born parents' mental health and sense of competence in parenting: a randomised controlled trial2017Inngår i: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, nr 12, artikkel-id e017600Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: To evaluate the effectiveness of a culturally tailored parenting support programme on Somali-born parents' mental health and sense of competence in parenting.

    DESIGN: Randomised controlled trial.

    SETTING: A city in the middle of Sweden.

    PARTICIPANTS: Somali-born parents (n=120) with children aged 11-16 years and self-perceived stress in their parenting were randomised to an intervention group (n=60) or a waiting-list control group (n=60).

    INTERVENTION: Parents in the intervention group received culturally tailored societal information combined with the Connect parenting programme during 12 weeks for 1-2 hours per week. The intervention consisted of a standardised training programme delivered by nine group leaders of Somali background.

    OUTCOME: The General Health Questionnaire 12 was used to measure parents' mental health and the Parenting Sense of Competence scale to measure parent satisfaction and efficacy in the parent role. Analysis was conducted using intention-to-treat principles.

    RESULTS: The results indicated that parents in the intervention group showed significant improvement in mental health compared with the parents in the control group at a 2-month follow-up: B=3.62, 95% CI 2.01 to 5.18, p<0.001. Further, significant improvement was found for efficacy (B=-6.72, 95% CI -8.15 to -5.28, p<0.001) and satisfaction (B=-4.48, 95% CI -6.27 to -2.69, p<0.001) for parents in the intervention group. Parents' satisfaction mediated the intervention effect on parental mental health (β=-0.88, 95% CI -1.84 to -0.16, p=0.047).

    CONCLUSION: The culturally tailored parenting support programme led to improved mental health of Somali-born parents and their sense of competence in parenting 2 months after the intervention. The study underlines the importance of acknowledging immigrant parents' need for societal information in parent support programmes and the importance of delivering these programmes in a culturally sensitive manner.

    CLINICAL TRIAL REGISTRATION: NCT02114593.

  • 53. Paul, Mandira
    et al.
    Danielsson, Kristina Gemzell
    Essen, Birgitta
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion2015Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, s. 1-4Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.

  • 54.
    Paul, Mandira
    et al.
    Uppsala University.
    Essén, Birgitta
    Uppsala University.
    Sariola, Salla
    University of Oxford.
    Iyengar, Sharad
    Action Research & Training for Health, Udaipur, Rajasthan, India.
    Soni, Sunita
    Action Research & Training for Health, Udaipur, Rajasthan, India.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Negotiating collective and individual agency: a qualitative study of young women's reproductive health in rural India2017Inngår i: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 27, nr 3, s. 311-324Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

  • 55. Paul, Mandira
    et al.
    Gemzell-Danielsson, Kristina
    Kiggundu, Charles
    Namugenyi, Rebecka
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Barriers and facilitators in the provision of post-abortion care at district level in central Uganda – a qualitative study focusing on task sharing between physicians and midwives2014Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, nr 28Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians’ and midwives’ perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care.

    Methods

    In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach.

    Results

    Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified.

    Conclusions

    Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

  • 56.
    Paul, Mandira
    et al.
    Uppsala Universitet.
    Iyengar, Kirti
    Karolinska institutet; ARTH, India.
    Essen, Birgitta
    Karolinska institutet.
    Gemzell-Danielsson, Kristina
    Karolinska institutet.
    Iyengar, Sharad D.
    ARTH, India.
    Bring, Johan
    Statisticon, Stockholm, Sweden..
    Soni, Sunita
    ARTH, India..
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Acceptability of home-assessment post medical abortion and medical abortion in a low-resource setting in Rajasthan, India: Secondary outcome analysis of a non-inferiority randomized controlled trial2015Inngår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, nr 9, artikkel-id e0133354Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education.

    Objective: To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India.

    Design: Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India.

    Population: Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years.

    Methods: Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1: 1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible.

    Main outcome measures: Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups.

    Results: 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001).

    Conclusion: Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

  • 57.
    Paul, Mandira
    et al.
    Uppsala Universitet.
    Iyengar, Kirti
    Karolinska institutet.
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Acceptability and feasability of home assessment using low-sensitivity pregnancy test in a low resource setting Rajasthan, India2015Konferansepaper (Fagfellevurdert)
  • 58.
    Paul, Mandira
    et al.
    Uppsala Universitet.
    Iyengar, Kirti
    Karolinska institutet.
    Iyengar, Sharad
    Action for Reserach in Health (ARTH).
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska Institutet.
    Simplified Follow-up after Medical Abortion using a Low-sensitivity Urinary Pregnancy Test and a Checklist in Rajasthan, India – Study Protocol and Intervention adaptation of a Randomised Control Trial2014Konferansepaper (Fagfellevurdert)
    Abstract [en]

    Background

    The WHO suggests that simplification of the medical abortion regime will contribute to an

    increased acceptability of medical abortion, among women as well as providers. It is expected

    that a home-based follow-up after a medical abortion will increase the willingness to opt for

    medical abortion as well as decrease the workload and service costs in the clinic. This study

    protocol describes an RCT that aims to evaluate the efficacy of home-based self-assessment

    after a medical abortion and the acceptability and feasibility of the intervention in a lowresource

    setting.

    Method/Design

    The study is a randomised, controlled, non-superiority trial that will evaluate the effectiveness

    and acceptability of self-assessment using a low-sensitivity pregnancy test and a checklist two

    weeks after medical abortion. Women screened to participate in the study are those with

    unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women

    randomised to the self-assessment group will use the low-sensitivity pregnancy test and the

    checklist at home, while the women in the clinic follow-up group will return to the clinic for

    routine follow-up carried out by a doctor. To ensure feasibility of the self-assessment

    intervention an adaption phase took place at the selected study sites before study initiation.

    This was to optimise and tailor-make the intervention and the study procedures and resulted

    in the development of a pictorial instruction sheet for how to use the low-sensitivity

    pregnancy test and the checklist of danger signs after a medical abortion.

    Discussion

    In this paper, we will describe the study protocol for a randomised control trial investigating

    the efficacy of simplified follow-up in terms of home-based self-assessment, two weeks after

    a medical abortion. Moreover, a description of the adaptation phase is included for a better

    understanding of the implementation of the intervention in a setting where literacy is low and

    the road-connections are poor.

    Trial registration

    Clinicaltrials.gov (No. NCT01827995)

  • 59.
    Paul, Mandira
    et al.
    Uppsala Universitet.
    Iyengar, Kirti
    Karolinska Institutet.
    Iyengar, Sharad
    Actiona for Reserach in Health (ARTH), India.
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Simplified follow-up after medical abortion using a low-sensitivity urinary pregnancy test and a pictorial instruction sheet in Rajasthan, India: study protocol and intervention adaptation of a randomised control trial2014Inngår i: BMC Women's Health, ISSN 1472-6874, E-ISSN 1472-6874, Vol. 14, artikkel-id 98Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    The World Health Organisation suggests that simplification of the medical abortion regime will contribute to an increased acceptability of medical abortion, among women as well as providers. It is expected that a home-based follow-up after a medical abortion will increase the willingness to opt for medical abortion as well as decrease the workload and service costs in the clinic.

    Trial design

    The study is a randomised, controlled, non-superiority trial .

    Methods

    Women screened to participate in the study are those with unwanted pregnancies and gestational ages equal to or less than nine weeks. Eligible women randomised to the home-based assessment group will use a low-sensitivity pregnancy test and a pictorial instruction sheet at home, while the women in the clinic follow-up group will return to the clinic for routine follow-up carried out by a doctor. The primary objective of the study is to evaluate the effectiveness of home-based assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet 10-14 days after an early medical abortion. Providers or research assistants will not be blinded during outcome assessment. To ensure feasibility of the self-assessment intervention an adaption phase took place at the selected study sites before study initiation. This was to optimise and tailor-make the intervention and the study procedures and resulted in the development of the pictorial instruction sheet for how to use the low-sensitivity pregnancy test and the danger signs after a medical abortion.

    Discussion

    In this paper, we will describe the study protocol for a randomised control trial investigating the efficacy of simplified follow-up in terms of home-based assessment, 10-14 days after a medical abortion. Moreover, a description of the adaptation phase is included for a better understanding of the implementation of the intervention in a setting where literacy is low and the road-connections are poor. Trial registration: Clinicaltrials.gov NCT01827995. Registered 04 May 2013

  • 60. Paul, Mandira
    et al.
    Iyengar, Sharad D
    Essén, Birgitta
    Gemzell-Danielsson, Kristina
    Iyengar, Kirti
    Bring, Johan
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Does mode of follow-up influence contraceptive use after medical abortion in a low-resource setting? Secondary outcome analysis of a non-inferiority randomized controlled trial2016Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, nr 1, artikkel-id 1087Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Post-abortion contraceptive use in India is low and the use of modern methods of contraception is rare, especially in rural areas. This study primarily compares contraceptive use among women whose abortion outcome was assessed in-clinic with women who assessed their abortion outcome at home, in a low-resource, primary health care setting. Moreover, it investigates how background characteristics and abortion service provision influences contraceptive use post-abortion.

    METHODS: A randomized controlled, non-inferiority, trial (RCT) compared clinic follow-up with home-assessment of abortion outcome at 2 weeks post-abortion. Additionally, contraceptive-use at 3 months post-abortion was investigated through a cross-sectional follow-up interview with a largely urban sub-sample of women from the RCT. Women seeking abortion with a gestational age of up to 9 weeks and who agreed to a 2-week follow-up were included (n = 731). Women with known contraindications to medical abortions, Hb < 85 mg/l and aged below 18 were excluded. Data were collected between April 2013 and August 2014 in six primary health-care clinics in Rajasthan. A computerised random number generator created the randomisation sequence (1:1) in blocks of six. Contraceptive use was measured at 2 weeks among women successfully followed-up (n = 623) and 3 months in the sub-set of women who were included if they were recruited at one of the urban study sites, owned a phone and agreed to a 3-month follow-up (n = 114).

    RESULTS: There were no differences between contraceptive use and continuation between study groups at 3 months (76 % clinic follow-up, 77 % home-assessment), however women in the clinic follow-up group were most likely to adopt a contraceptive method at 2 weeks (62 ± 12 %), while women in the home-assessment group were most likely to adopt a method after next menstruation (60 ± 13 %). Fifty-two per cent of women who initiated a method at 2 weeks chose the 3-month injection or the copper intrauterine device. Only 4 % of women preferred sterilization. Caste, educational attainment, or type of residence did not influence contraceptive use.

    CONCLUSIONS: Simplified follow-up after early medical abortion will not change women's opportunities to access contraception in a low-resource setting, if contraceptive services are provided as intra-abortion services as early as on day one. Women's postabortion contraceptive use at 3 months is unlikely to be affected by mode of followup after medical abortion, also in a low-resource setting. Clinical guidelines need to encourage intra-abortion contraception, offering the full spectrum of evidence-based methods, especially long-acting reversible methods.

    TRIAL REGISTRATION: Clinicaltrials.gov NCT01827995.

  • 61.
    Paul, Mandira
    et al.
    Uppsala Universitet.
    Josaphat, Byamugisha
    Makerere Universitetet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Larsson, Elin
    karolinska institutet.
    Health care providers balancing norms and practice: Challenges and opportunities in contraceptive counselling to young people in Uganda2015Konferansepaper (Fagfellevurdert)
  • 62. Paul, Mandira
    et al.
    Näsström, Sara B
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Kiggundu, Charles
    Larsson, Elin C
    Healthcare providers balancing norms and practice: challenges and opportunities in providing contraceptive counselling to young people in Uganda - a qualitative study2016Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, nr 1, artikkel-id 30283Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Pregnancies among young women force girls to compromise education, resulting in low educational attainment with subsequent poverty and vulnerability. A pronounced focus is needed on contraceptive use, pregnancy, and unsafe abortion among young women.

    OBJECTIVE: This study aims to explore healthcare providers' (HCPs) perceptions and practices regarding contraceptive counselling to young people.

    DESIGN: We conducted 27 in-depth interviews with doctors and midwives working in seven health facilities in central Uganda. Interviews were open-ended and allowed the participant to speak freely on certain topics. We used a topic guide to cover areas topics of interest focusing on post-abortion care (PAC) but also covering contraceptive counselling. Transcripts were transcribed verbatim and data were analysed using thematic analysis.

    RESULTS: The main theme, HCPs' ambivalence to providing contraceptive counselling to sexually active young people is based on two sub-themes describing the challenges of contraceptive counselling: A) HCPs echo the societal norms regarding sexual practice among young people, while at the same time our findings B) highlights the opportunities resulting from providers pragmatic approach to contraceptive counselling to young women. Providers expressed a self-identified lack of skill, limited resources, and inadequate support from the health system to successfully provide appropriate services to young people. They felt frustrated with the consultations, especially when meeting young women seeking PAC.

    CONCLUSIONS: Despite existing policies for young people's sexual and reproductive health in Uganda, HCPs are not sufficiently equipped to provide adequate contraceptive counselling to young people. Instead, HCPs are left in between the negative influence of social norms and their pragmatic approach to address the needs of young people, especially those seeking PAC. We argue that a clear policy supported by a clear strategy with practical guidelines should be implemented alongside in-service training including value clarification and attitude transformation to equip providers to be able to better cater to young people seeking sexual and reproductive health advice.

  • 63. Påfs, J.
    et al.
    Rulisa, S.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Binder-Finnema, P.
    Musafili, A.
    Essén, B.
    Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers2020Inngår i: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 80, artikkel-id 102568Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objective: Rwanda amended its abortions law in 2012 to allow for induced abortion under certain circumstances. We explore how Rwandan health care providers (HCP) understand the law and implement it in their clinical practice. Design: Fifty-two HCPs involved in post-abortion care in Kigali were interviewed by qualitative individual in-depth interviews (n =32) and in focus group discussions (n =5) in year 2013, 2014, and 2016. All data were analyzed using thematic analysis. Findings: HCPs express ambiguities on their rights and responsibilities when providing abortion care. A prominent finding was the uncertainties about the legal status of abortion, indicating that HCPs may rely on outdated regulations. A reluctance to be identified as an abortion provider was noticeable due to fear of occupational stigma. The dilemma of liability and litigation was present, and particularly care providers’ legal responsibility on whether to report a woman who discloses an illegal abortion. Conclusion: The lack of professional consensus is creating barriers to the realization of safe abortion care within the legal framework, and challenge patients right for confidentiality. This bring consequences on girl's and women's reproductive health in the setting. Implications for practice: To implement the amended abortion law and to provide equitable maternal care, the clinical and ethical guidelines for HCPs need to be revisited. © 2019

  • 64. Påfs, Jessica
    et al.
    Musafili, Aimable
    Binder-Finnema, Pauline
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Rulisa, Stephen
    Essén, Birgitta
    Beyond the numbers of maternal near-miss in Rwanda - a qualitative study on women's perspectives on access and experiences of care in early and late stage of pregnancy.2016Inngår i: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, artikkel-id 257Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Rwanda has made remarkable progress in decreasing the number of maternal deaths, yet women still face morbidities and mortalities during pregnancy. We explored care-seeking and experiences of maternity care among women who suffered a near-miss event during either the early or late stage of pregnancy, and identified potential health system limitations or barriers to maternal survival in this setting.

    METHODS: A framework of Naturalistic Inquiry guided the study design and analysis, and the 'three delays' model facilitated data sorting. Participants included 47 women, who were interviewed at three hospitals in Kigali, and 14 of these were revisited in their homes, from March 2013 to April 2014.

    RESULTS: The women confronted various care-seeking barriers depending on whether the pregnancy was wanted, the gestational age, insurance coverage, and marital status. Poor communication between the women and healthcare providers seemed to result in inadequate or inappropriate treatment, leading some to seek either traditional medicine or care repeatedly at biomedical facilities.

    CONCLUSION: Improved service provision routines, information, and amendments to the insurance system are suggested to enhance prompt care-seeking. Additionally, we strongly recommend a health system that considers the needs of all pregnant women, especially those facing unintended pregnancies or complications in the early stages of pregnancy.

  • 65. Påfs, Jessica
    et al.
    Musafili, Aimable
    Finnema, Pauline Binder
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Rulisa, Stephen
    Essén, Birgitta
    'They would never receive you without a husband': Paradoxical barriers to antenatal care scale-up in Rwanda2015Inngår i: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, nr 12, s. 1149-1156Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss').

    DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda.

    FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy.

    CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

  • 66.
    Påfs, Jessica
    et al.
    Uppsala University.
    Musafili, Aimable
    Uppsala University.
    Finnema-Binder, Pauline
    Uppsala University.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Essen, Birgitta
    Uppsala Universitet.
    Barriers to safe motherhood in Rwanda. Explored by in-depth interviews with women experiencing near miss event2015Konferansepaper (Fagfellevurdert)
  • 67. Rehnström Loi, Ulrika
    et al.
    Gemzell-Danielsson, Kristina
    Faxelid, Elisabeth
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska institutet.
    Health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data.2015Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 15, nr 139Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.

    METHODS: A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.

    RESULTS: Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers' attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.

    CONCLUSIONS: Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.

  • 68. Rehnström Loi, Ulrika
    et al.
    Lindgren, Matilda
    Faxelid, Elisabeth
    Oguttu, Monica
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska Intitutet.
    Decision-making preceding induced abortion: a qualitative study of women’s experiences in Kisumu, Kenya2018Inngår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 15, artikkel-id 166Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background

    Unwanted pregnancies and unsafe abortions are prevalent in regions where women and adolescent girls have unmet contraceptive needs. Globally, about 25 million unsafe abortions take place every year. In countries with restrictive abortion laws, safe abortion care is not always accessible. In Kenya, the high unwanted pregnancy rate resulting in unsafe abortions is a serious public health issue. Gaps exist in knowledge regarding women’s decision-making processes in relation to induced abortions in Kenya. Decision-making is a fundamental factor for consideration when planning and implementing contraceptive services. This study explored decision-making processes preceding induced abortion among women with unwanted pregnancy in Kisumu, Kenya.

    Methods

    Individual face-to-face in-depth interviews were conducted with nine women aged 19–32 years old. Women who had experienced induced abortion were recruited after receiving post-abortion care at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) or Kisumu East District Hospital (KDH) in Kisumu, Kenya. In total, 15 in-depth interviews using open-ended questions were conducted. All interviews were tape-recorded, transcribed and coded manually using inductive content analysis.

    Results

    Respondents described their own experiences regarding decision-making preceding induced abortion. This study shows that the main reasons for induced abortion were socio-economic stress and a lack of support from the male partner. In addition, deviance from family expectations and gender-based norms highly influenced the decision to have an abortion among the interviewed women. The principal decision maker was often the male partner who pressed for the termination of the pregnancy indirectly by declining his financial or social responsibilities or directly by demanding termination. In some cases, the male partner controlled decision-making by arranging an unsafe abortion without the woman’s consent. Strategic choices regarding whom to confide in were employed as protection against abortion stigma. This contributed to a culture of silence around abortion and unwanted pregnancy, a factor that made women more vulnerable to complications.

    Conclusions

    The findings suggest that financial, social and gender-based dependencies influence women’s agency and perceived options in decision-making regarding abortion.

  • 69. Rehnström Loi, Ulrika
    et al.
    Otieno, Beatrice
    Oguttu, Monica
    Gemzell-Danielsson, Kristina
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska Institutet.
    Faxelid, Elisabeth
    Makenzius, Marlene
    Abortion and contraceptive use stigma: a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya.2019Inngår i: Sexual and reproductive health matters, ISSN 2641-0397, Vol. 27, nr 3, artikkel-id 1652028Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use - the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13-21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = .003 and 50.6%, p = .007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p = .899) or contraceptive use stigma (p = .823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya.

  • 70.
    Råssjö, Eva-Britta
    et al.
    Falun Cent Hosp, Dept Obstet & Gynaecol, Falun, Sweden; Clin Res Ctr, Dalarna, Sweden.
    Byrskog, Ulrika
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Falun Cent Hosp, Dept Obstet & Gynaecol, Falun, Sweden; Dalarna Univ, Sch Hlth & Social Sci, Falun, Sweden.
    Samir, Raghad
    Falun Cent Hosp, Dept Obstet & Gynaecol, Falun, Sweden ; Clin Res Ctr, Dalarna, Sweden.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Karolinska Inst, Dept Womens & Childrens Hlth, S-10401 Stockholm, Sweden.
    Somali women’s use of maternity health services and the outcome of their pregnancies: a descriptive study comparing Somali migrants with inborn Swedish Women2013Inngår i: Sexual & Reproductive HealthCare, ISSN 1877-5756, E-ISSN 1877-5764, Vol. 4, nr 3, s. 99-106Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives: To describe how Somali immigrant women in a Swedish county access and use the antenatal care and health services, their reported and observed health problems and the outcome of their pregnancies.

    Study design: Retrospective, descriptive study, comparing data obtained from the records of antenatal and obstetric care for Somali born women with the same data for parity matched women born in Sweden giving birth between 2001 and 2009.

    Main outcome measures: Utilisation of antenatal health care (timing and number of visits), pregnancy complications (severe hyperemesis, anaemia, preeclampsia, urinary tract infections), mode of birth (normal vaginal, operative vaginal, caesarean), and infant outcomes (preterm birth, birth weight, and perinatal mortality)

    Results: Compared to the 523 Swedish-born women the 262 Somali women booked later and made less visits for antenatal care. They were more likely to have anaemia, severe hyperemesis and recurrent urinary tract infection. Emergency caesarean section (OR 9.90, CI 1.16-3.10), especially before start of labour (OR 4.96, CI 1.73-14.22), high perinatal mortality  with seven versus one perinatal deaths and small for date infants (OR 2.95, CI 1.49-5.82) was also more prevalent.

    Conclusion: Pregnant Somali immigrant women constitutes a vulnerable group that needs targeted attention. There is an increased risk for intrauterine foetal death, small for date and low birth weight infants as well as serious maternal morbidity.

     

     

     

  • 71.
    Sjöström, Susanne
    et al.
    Karolinska Insitutet.
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India2016Inngår i: BMC Medical Education, ISSN 1472-6920, E-ISSN 1472-6920, Vol. 16, nr 1, artikkel-id 8Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND:

    Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education.

    METHOD:

    We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach.

    RESULTS:

    The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future.

    CONCLUSIONS:

    To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.

  • 72.
    Sjöström, Susanne
    et al.
    Karolinska Institutet.
    Essen, Birgitta
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad.
    Medical students are afraid to include abortion in their practices: in-depth interviews in Maharastra, India2015Konferansepaper (Fagfellevurdert)
  • 73.
    Sjöström, Susanne
    et al.
    Karolinska Institutet.
    Essen, Birgitta
    Uppsala Universitet.
    Syden, Filip
    Uppsala Universitet.
    Gemzell-Danielsson, Kristina
    Karolinska Institutet.
    Klingberg-Allvin, Marie
    Högskolan Dalarna, Akademin Utbildning, hälsa och samhälle, Omvårdnad. Uppsala universitet; Karolinska Institutet.
    Medical students' attitudes and perceptions on abortion: a cross-sectional survey among medical interns in Maharastra, India2014Inngår i: Contraception, ISSN 0010-7824, E-ISSN 1879-0518, Vol. 90, nr 1, s. 42-46Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction: Although abortion care has been an established routine since decades in India, 8% of maternal mortality is attributed to unsafe abortion. Increased knowledge and improved attitudes among health care providers have a potential to reduce barriers to safe abortion care by reducing stigma and reluctance to provide abortion. Previous research has shown that medical students' attitudes can predict whether they will perform abortions. The objective of our study was to explore attitudes toward abortion among medical interns in Maharastra, India.

    Study Design: A cross-sectional survey was carried out among 1996 medical interns in Maharastra, India. Descriptive and analytical statistics were used to interpret the study instrument.

    Results: Almost one quarter of the respondents considered abortion to be morally wrong, one fifth did not find abortions for unmarried women acceptable and one quarter falsely believed that a woman needs her partner or spouse's approval to have an abortion. Most participants agreed that unsafe abortion is a serious health problem in India. A majority of the respondents rated their knowledge of sexual and reproductive health as good, but only 13% had any clinical practice in abortion care services.

    Conclusion: Disallowing attitudes toward abortion and misconceptions about the legal regulations were common among the surveyed medical students. Knowledge and attitudes toward abortion among future physicians could be improved by amendments to the medical education, potentially increasing the number of future providers delivering safe and legal abortion services.

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