Domestication of the Maputo Protocol in the Democratic Republic of Congo: Leveraging regional human rights commitments for abortion decriminalization and access.

The Maputo Protocol, adopted over 20 years ago, is a promising regional treaty for advancing gender equity and sexual and reproductive health and rights. This instrument has driven progress in women's health and rights across Africa, with much remaining to achieve to realize its full potential for women and girls, including access to safe abortion. The present paper shares the strategies and lessons from the Democratic Republic of Congo's (DRC) reform centered on the domestication of the Protocol, specifically applying its commitments on abortion decriminalization and access.

Adaptations to comprehensive abortion care during the COVID-19 pandemic: case studies of provision in Bolivia, Mali, Nepal, and the occupied Palestinian territory.

The COVID-19 pandemic impacted comprehensive abortion care provision. To maintain access to services while keeping individuals safe from infection, many organisations adapted their programmes. We conducted a programme evaluation to examine service adaptations implemented in Bolivia, Mali, Nepal, and the occupied Palestinian territory.

Telehealth for Addressing Sexual and Reproductive Health and Rights Needs During the COVID-19 Pandemic and Beyond: A Hybrid Telemedicine-Community Accompaniment Model for Abortion and Contraception Services in Pakistan.

The COVID-19 pandemic led overburdened health care systems to deprioritize essential sexual and reproductive healthcare, including abortion and contraception care, while accelerating shifts in healthcare delivery to digital technologies. However, in many countries, including Pakistan, inequalities in access to digital technologies remain, presenting an opportunity for interventions that both increase access to deprioritized sexual and reproductive health and rights (SRHR) services and overcome the digital divide in delivering digital solutions to those in need of SRHR services. In June 2020, Ipas Pakistan partnered with Sehat Kahani (SK), a local health care NGO and telehealth service, and an existing network of Lady Health Workers (LHWs) to launch a novel hybrid telemedicine-community accompaniment pilot.

Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade.

Objective: We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women's opinions on their overall experience of PPH care.

Methods: This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction.

The Safety and Feasibility of a Family First Aid Approach for the Management of Postpartum Hemorrhage in Home Births: A Pre-post Intervention Study in Rural Pakistan.

Objective: To evaluate the safety and feasibility of a Family First Aid approach whereby women and their families are provided misoprostol in advance to manage postpartum hemorrhage (PPH) in home births.

Methods: A 12-month prospective, pre-post intervention study was conducted from February 2017 to February 2018. Women in their second and third trimesters were enrolled at home visits.

A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt.

Background: Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed.

Methods: This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt.

How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin?

Objective: We aimed to better understand how well postpartum blood loss and common postpartum hemorrhage (PPH) definitions (i.e. blood loss ≥500ml = PPH, ≥1000ml = "severe" PPH) correlate with postpartum anemia and fall in hemoglobin.

The effectiveness and safety of introducing condom-catheter uterine balloon tamponade for postpartum haemorrhage at secondary level hospitals in Uganda, Egypt and Senegal: a stepped wedge, cluster-randomised trial.

Objective: To assess the effectiveness of introducing condom-catheter uterine balloon tamponade (UBT) for postpartum haemorrhage (PPH) management in low- and middle-income settings.

Design: Stepped wedge, cluster-randomised trial.

Setting: Eighteen secondary-level hospitals in Uganda, Egypt and Senegal.

Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial.

Background: Oxytocin for postpartum hemorrhage (PPH) prophylaxis is commonly administered by either intramuscular (IM) injection or intravenous (IV) infusion with both routes recommended equally and little discussion of potential differences between the two. This trial assesses the effectiveness and safety of 10 IU oxytocin administered as IM injection versus IV infusion and IV bolus during the third stage of labor for PPH prophylaxis.

Methods: In two tertiary level Egyptian maternity hospitals, women delivering vaginally without exposure to pre-delivery uterotonics were randomized to one of three prophylactic oxytocin administration groups after delivery of the baby.

Use of an at-home multilevel pregnancy test and an automated call-in system to follow-up the outcome of medical abortion.

Objective: To assess the feasibility of using an at-home multilevel pregnancy test (MLPT) and interactive voice response (IVR) call-in system for remote follow-up of medical abortion.

Methods: A prospective pilot study was conducted among women who had a medical abortion at up to 70 days at a clinic in Mexico City, Mexico, between June 1, 2015, and January 30, 2016. Participants took an MLPT at the initial clinic visit and another MLPT at home 2 weeks later.

Serial multilevel urine pregnancy testing to assess medical abortion outcome: a meta-analysis.

Objectives: To summarize data on the accuracy of a strategy designed to exclude ongoing pregnancy after medical abortion treatment by observing a decline in urine human chorionic gonadotropin (hCG) concentration as estimated by multilevel urine pregnancy tests (MLPTs) performed before and after treatment.

Study Design: We collated original data from seven studies performed by our organization that evaluated the accuracy of the MLPT strategy for assessment of outcome of medical abortion. Our first analysis included data from the five studies in which each participant was evaluated both with the MLPT strategy and with ultrasound or other clinical assessment.

Self-administered multi-level pregnancy tests in simplified follow-up of medical abortion in Tunisia.

Background: This study was conducted to assess the efficacy and acceptability of using a multi-level pregnancy test (MLPT) combined with telephone follow-up for medical abortion in Tunisia, where the majority of providers are midwives.

Methods: Four hundred and four women with gestational age ≤ 70 days' LMP seeking medical abortion at six study sites were enrolled in this open-label trial. Participants administered a baseline MLPT at the clinic prior to mifepristone administration and were asked to take a second MLPT at home and to call in its results before returning the day of their scheduled follow-up visit 10-14 days later.

Misoprostol for primary versus secondary prevention of postpartum haemorrhage: a cluster-randomised non-inferiority community trial.

Objective: To assess whether secondary prevention, which preemptively treats women with above-average postpartum bleeding, is non-inferior to universal prophylaxis.

Design: A cluster-randomised non-inferiority community trial.

Setting: Health sub-centres and home deliveries in the Bijapur district of Karnataka, India.

A double-blind randomized controlled trial of mifepristone or placebo before buccal misoprostol for abortion at 14-21 weeks of pregnancy.

Objective: To assess differences in outcomes of misoprostol with or without mifepristone for second-trimester abortion.

Methods: A randomized, double-blind, placebo-controlled trial of buccal misoprostol following placebo or 200mg mifepristone was done in Tunisia among women presenting for abortions at 14-21 weeks of pregnancy between August 2009 and December 2011. Women with a live fetus, a closed cervical os, no cervical bleeding, and no contraindications to study drugs were eligible and underwent randomization (block size 10).

A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days' LMP: a prospective comparative open-label trial.

Objective: To test the effectiveness and acceptability of an outpatient medical abortion protocol with 200 mg mifepristone and 400 mcg sublingual misoprostol at 64-70 days' last menstrual period (LMP) and compare it to the already known efficacy of the 57-63 days' LMP gestational age range.

Study Design: We conducted a prospective, comparative open-label trial in six hospitals and clinics in Ukraine, Georgia, India and Tunisia. We enrolled 714 reproductive age women with pregnancies 57 to 70 days who presented requesting abortion.

Misoprostol for the management of postpartum bleeding: a new approach.

Excessive postpartum hemorrhage (PPH) is a leading cause of maternal death globally. Current approaches to address PPH at the community level focus on reducing the incidence of PPH, but often fail to address the issue of PPH treatment. Given that institutional delivery is not yet a reality for all women, comprehensive care for excessive bleeding after delivery needs to be available at the community level.

Comparison of misoprostol-only and combined mifepristone-misoprostol regimens for home-based early medical abortion in Tunisia and Vietnam.

Objective: To assess the potential advantages of combined mifepristone-misoprostol versus misoprostol-only for early medical abortion.

Methods: A double-blind randomized placebo controlled study was conducted that enrolled 441 pregnant women (<63 days since last menstrual period) at 2 hospitals in Tunisia and Vietnam. The mifepristone-misoprostol group (n=220) received 200mg of mifepristone on day 1 and 800 μg buccal misoprostol followed by placebo 3 hours later on day 2.

Comparing two early medical abortion regimens: mifepristone+misoprostol vs. misoprostol alone.

Background: Nonsurgical abortion methods have the potential to improve access to high-quality abortion care. Until recently, availability and utilization of mifepristone medical abortion in low-resource countries were restricted due to the limited availability and perceived high cost of mifepristone, leading some providers and policymakers to support use of misoprostol-only regimens. Yet, this may not be desirable if misoprostol-only regimens are considerably less effective and ultimately more costly for health care systems.

A randomized controlled trial of 400-μg sublingual misoprostol versus manual vacuum aspiration for the treatment of incomplete abortion in two Egyptian hospitals.

Objective: To compare the safety, efficacy, and acceptability of 400-μg sublingual misoprostol with that of manual vacuum aspiration (MVA) in 2 Egyptian hospitals.

Methods: Participating women were randomized to either MVA or misoprostol treatment for incomplete abortion. The primary outcome, complete uterine evacuation, was determined 1 week later, as were adverse effects, change in hemoglobin, acceptability, and satisfaction.

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial.

Background: Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin.

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial.

Background: Oxytocin, the standard of care for treatment of post-partum haemorrhage, is not available in all settings because of refrigeration requirements and the need for intravenous administration. Misoprostol, an effective uterotonic agent with several advantages for resource-poor settings, has been investigated as an alternative. This trial established whether sublingual misoprostol was similarly efficacious to intravenous oxytocin for treatment of post-partum haemorrhage in women not exposed to oxytocin during labour.

Increasing women's choices in medical abortion: a study of misoprostol 400 microg swallowed immediately or held sublingually following 200 mg mifepristone.

Objectives: To assess the efficacy and acceptability of two misoprostol regimens (400 microg oral or sublingual) following mifepristone for medical abortion.

Methods: Women seeking abortion with gestations of 56 days or less since onset of their last menstrual period were offered medical abortion as an alternative to a surgical procedure. A total of 207 eligible and consenting women were given mifepristone (200 mg oral) and the option of taking 400 microg misoprostol either orally or sublingually two days later, with the option of home-use.

Challenges to microbicide introduction in South Africa.

Qualitative research was conducted in South Africa to determine perceptions about intra-vaginal microbicides in order to better understand the socioeconomic, cultural and structural contexts for the support of future introduction of this new HIV prevention method. Focus group discussions and in-depth interviews were conducted at community, health service, and policy levels of inquiry. The main study site was a black working class urban area close to Cape Town.