Midwives can safely treat incomplete abortion at district level in Uganda

One scientific study led by researchers at Sweden’s Karolinska Institutet is expected to form the basis of new international recommendations for the treatment of incomplete abortion. The study, published in the journal The Lancet, shows that midwives can safely and effectively diagnose and treat incomplete abortion at district level in Uganda.

Complications from spontaneous and unsafe abortions significantly add to the maternal mortality and morbidity figures. The majority of pregnancy related deaths occur in low-income countries where induced abortion is restricted, unmet need for contraception high, and women’s status is low.

It is estimated that Africa caters for the highest rates of unsafe abortions globally. Access to adequate contraceptive counselling, safe abortion, and post abortion care (PAC) are key interventions identified to contribute to a reduction of maternal deaths. Incomplete abortion is a common complication following a failed abortion treatment or spontaneous abortion (miscarriage). Incomplete abortion is a potentially life-threatening condition that can effectively and safely be treated with the medicine misoprostol, a prostaglandin analogue that causes the uterus to contract and empty its contents.

In Uganda, the legal status of induced abortion is restricted, and illegal and unsafe abortions are common, resulting in large number of incomplete abortions. With technical support from the WHO, researchers at Karolinska Institutet, Dalarna University and colleagues from Makerere University in Uganda conducted a study that includes around 1,000 women recruited in six different districts in rural, peri-urban and urban settings in Uganda.

Associate professor Marie Klingberg-Allvin, Dalarna University and Karolinska Institutet who coordinated the study describes: “ Women admitted to district health centres with incomplete abortion where randomly assigned to be diagnosed and treated with misoprostol from either a midwife or doctor. Our study shows that midwives can equally safe as physicians handle the medicinal treatment of incomplete abortions in rural districts of Uganda with misoprostol. The findings may be used to revise both health care guidelines and curricula for midwifery education, enabling midwives to be official providers of post abortion care using misoprostol“.

Amanda Cleeve, midwife and PhD student, Department of Women’s and Children’s Health, Karolinska Institutet has been involved in the implementation of the study is now also analysing women’s acceptability to be treated with misoprostol by midwives and the contraceptive use and uptake after the treatment. “ Women’s experiences and acceptability of treatment of incomplete abortion with misoprostol as well as contraceptive use and uptake is important to understand when designing health care that meet the reproductive needs of women”.

As midwives far outnumber the doctors in rural area of Uganda and many other low-income countries, a task shift in post abortion care has the potential to increase access to treatment of incomplete abortions, which ultimately saves women’s lives.

The study will form the basis of new guidelines from the WHO, which will recommend midwives to be main providers in the medical management of incomplete abortions in the first trimester” says Kristina Gemzell-Danielsson, Professor at the Department of Women’s and Children’s Heath at Karolinska Institutet and principal investigator of the study.


Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial.

Marie Klingberg-Allvin, Amanda Cleeve, Susan Atuhairwe, Nazarius Mbona Tumwesigye, Elisabeth Faxelid, Josaphat Byamugisha, and Kristina Gemzell Danielsson,The Lancet, online 27 March 2015.

Access the publication here.