Rolesformobiletechnologyandself-managementinstrengtheningautonomyinabortioncare

FIAPAC.October2016,Portugal.

DeborahConstant* JaneHarries*KristinaGemzell-Danielsson§CaitlinGerdts#

*Women’sHealthResearchUnit,UniversityofCapeTown,SouthAfrica§KarolinskaInstitutet,Stockholm,Sweden#IbisReproductiveHealth,SanFrancisco,US

Reproductiverightsandabortionlaws@2016

UnitedNationsGeneralCommentNo.22(2016)ontheRighttoSexualandReproductiveHealth:

UNE/C.12/GC/22. 4March2016

Statesarerequiredtotoadoptmeasuresto:

• Liberalizerestrictiveabortionlaws

• Guaranteeaccesstosafeabortionservices

CRR:http://worldabortionlaws.com/map/ Accessed12Sep2016

SA:CTOPA1996

Commonbarrierstoaccesswhereabortionislegal

• Scarcityoftrainedandwillingproviders• Scarcefacilitiesconcentratedinurbancenters

• Over-medicalizationofprocedures– multiplevisits,ultrasoundexaminations

• Lackofinformationandsupportsystemsesp.forpoorer,hardtoreach

women

• Shortagesofhealthcareprofessionalswillworsenincomingyearsesp.inLMICs- tasksharingcomponentsofabortioncare(WHO,2015)

• Wherewomenhaveaccuratesourceofinformation• WherewomenhaveaccesstoaHCPifneeded• Wheremifepristoneandmisoprostolareused• Usingpregnancytestsandchecklists

WHO:Health workerrolesinproviding safeabortion careandpost-abortion contraception. 2015

Tasksharingmedicalabortion:self-management(WHO2015)

Internationalagencies

Users

Businesses(Telecoms)

Healthcareprofessionals

Governmentbodies

Researchers

Mobiletechnologyandhealth:therolepayersmHealth:Theuseofmobiletechnologytosupportmedicalandpublichealthcarepractice

Challenges:coordinationbetweenroleplayerswhosecultures,objectivesandtraditionsaredifferent

FeasibilityofmHealthintheSouthAfricansetting:ThereachofmHealth

Source:GSMAmhealth:mhealth feasibility SouthAfrica2014

2014: Surveyofurbanlow-incomesuburbnearCapeTown(clinicattendees)

• 89%ownaphone

• 49% havesmartphoneoperability

• 75% don’tsharetheirphoneKhayelitsha mobilehealth phoneusesurvey.MSF,2014

mHealthintheSouthAfricansetting:phoneusageandpreferredmodalityforhealthinformation(clinicattendees)

Khayelitsha mobilehealth phoneusesurvey.MSF,2014

Autonomyinsafeabortioncare

How:MA orSA?

IFMA -Where:clinicorhome?

IFMA -Support:

In whatform?

Autonomy:• choice• self-sufficiency

Riskmanagement/supportifwantedorneeded

Healthcareprovider?Helplines?TextMessaging?

mHealthforabortion:self-assessingeligibility

i calculatestudy:Exploredacceptability&usabilityofonlinewebsitetoself-assesseligibilityforMA(gestationalagecalculator+prompts+questions)

Self-assessingeligibility:i calculatestudy

Mainfindings:• MostlyaccuraterecallofLMP,butsomeextremeoutliers

• Calendarpromptswerehelpfulfor43%ofthoseuncertainaboutLMPdate

• Most(91%)foundcalculatoreasytouse

• Most(94%)thoughtwebsitecouldbehelpfulwhenconsideringabortion

2.mHealthforabortion:SMSsupportwhileself-managingMAwithoutprovidersupport

• SouthAfrica(2011/12,2014/15)RCTs13timed,automatedSMSssentover2weeksremindersaboutprocess,S&Sofcomplications-mostlyverywellliked

• Indonesia(2014)IDIs– infavour ofsmartphoneappforinformationonsafeabortionandreminders

• Cambodia(2014/15)RCT- 80%infavour of SMSforsupport,remindersandself-assessment

Hihopeyou'regood.Youmaystillbespotting(abitofbleeding orbrownbits).Ifyou'rebleedinglikeanormalperiodormore,tell yourclinicprovideraboutthis

Day13

Constant etalContraception 2014, Gerdts etalAPHA2014, Gerdts etal(inprep)

SMSsupport(SA;2011/2012RCT)Outcomesatfollow-upclinicvisit

0102030405060708090100

Bleeding Pain Sideeffects Process

InterventionN=197ControlN=184

Interventio

n

Control

%ofwomenverywellpreparedfor:OR:2.9

(1.62to5.07)

OR:1.6

(1.02to2.59)

OR:1.8

(1.07to2.89)

OR:2.7

(1.20to6.04)

“Ialwaysknewwhat isgoingtohappensothatkeptmegoingbecauseifitwasnotfortheSMSsIwouldhavecomebackafter2days.SotheyhelpedmealotbecauseIdidn'tevencalltheclinic.Theyweremyhope.”

“SometimestheSMSscomfortedme.IfelttheSMSsunderstoodwhat Iwasgoingthrough.Feltlikeafriend

“comforted&calmedme&theyalsokeptmealerted”(27yr.old,nopriorMA,1child,unemployed) “theyhelpmetocalmdown,hadnoonetotalk

to”(33yr.old,1priorMA,2children,unemployed)

2014/2015

2011/2012

SMSsupportfeedback(SA;2014/20152011/2012)• 4%: SMSfailurerate• 96%:SMSswerehelpful/veryhelpfulinmanagingMAathome• 25%: Hadconcernaboutphoneprivacy

Othersettings:useofmobileandinformation& communicationtechnologyinstrengtheningautonomyinabortioncare

Remotefollow-upusingphonecalls/textmessagestowomen’smobilephones.UK(RUOK?,2014)RCT:mostpreferphoneFU

Remoteprovisionandfollow-upusingtelemedicine(provisionofMAatadistanceusingICT)

Directtopatient–• WOW- onlineconsultationandhelplineifneeded• Canada,Australia– localscreening,remoteconsultation,drugs/prescriptionmailed• ToberesearchedinUSIowamodel(US)- localscreening,remoteconsultation,drugsprovidedatclinicGrossmanDetal.ObstetricsandGynecology.2011

3.Self-assessingcompletenessofabortionoutcome(supportedbymHealth)Background

2011: Symptomhistoryaloneunreliabletodetectongoingpregnancy

2012– 2016:US,Vietnam,Moldova,Tunisia– Multi-levelurinepregnancytest:somedifficultieswithinterpretationoftest- interpretation?repeatedtest

2012– 2015:Europe,UK,India:Low-sensitivityurinepregnancytest:Simpletest,butoccasionalfalsenegativeresults,one-offtest

2014-2016:SouthAfricanstudyusingnew checkToP® Lowsensitivityurinepregnancytest(LSUPT) Rapidtest,detects≥1000mIU/mLhCGinurine

Studyrationale

Somedifficultiesidentifiedinearlierstudieswithrespecttothemulti-levelandlow-sensitivityurinepregnancytests

StudyQuestions:

• Can/WillwomenattendingpublicsectorprimarylevelabortionfacilitiesinSouthAfricausethetestcorrectly(storage,steps,timing)?

• Canwomeninterpretthetestresults(faintlines?)

• Dowomenwanttoself-assessorreturntoclinic?

Materialsandmethods• Anon-inferiorityRCTin6publicsectorprimarylevelabortionclinics,SA.• Studyarms:Guideddemonstrationvs.instruction-onlyonLSUPT• Inferioritymarginsetat6%.

• Primaryoutcome:Accurateassessmentofmedicalabortionoutcome.IncompleteMA:requiringadditionalmedicalorsurgicalintervention.

• Eligibilitycriteria:18+years,confirmedintra-uterinepregnancyupto63days,willingtoreceiveabortion-relatedtextmessagesontheirphone.

StudyaimToevaluateaccuracyofself-assessmentofmedicalabortionusingthecheckToP® low–sensitivitypregnancytest(LSUPT),combinedwithachecklistandphonetextmessages.

•Baselineinterview

•Standardcare:MedicalabortionIntervention

•AutomatedtimedreminderSMSs•Self-AssessmentwithcheckToP®LSUPTandchecklist

•Standardcare:In-clinicproviderassessment

• Follow-upinterview

Studymethods:procedures

Results:In-clinicproviderassessmentat2wk.followup:DemonstrationvsInstruction-only

91%

1% 3% 5%

91%

1% 4% 4%0%

10%20%30%40%50%60%70%80%90%

100%

Completeabortion

Ongoingpregnancy

Incompleteabortion(MVA)

Incompleteabortion

(misoprostol)

Demonstration

Instruction

Results:PrimaryOutcome:Accurateself-assessmentofMAoutcome

Results:Preferredmethodoffollow-upDemonstrationvsInstruction-only

2%

1%

1%

5%

91%

0%

1%

0%

1%

4%

93%

1%

0% 20% 40% 60% 80% 100%

In-clinicassessment

LSUPTONLY*

LSUPT+checklist*

LSUPT+SMSs*

LSUPT+checklist+SMSs*

LSUPT+checklist+SMSs**

Demonstration

Instruction

*AndvisittheclinicifIneedto**AndcalltheclinicifIneedto

Conclusionsandrecommendations

üNon-Inferiorityof instruction comparedtodemonstration isinconclusive.Simulateddemonstrationcanberecommended

ü Carefulcounsellingisneededtoensurenoongoingpregnanciesaremissed.

ü Women’schoiceforassessmentofmedicalabortionistheLSUPT+checklist+SMSs

ü SMSsareanalternativeeffectivewayofsupportingwomenandmanagingriskincaseofcomplicationsorofongoingpregnancy

Whatnow?• EngagementwithSRHNGOsonimplementingmhealthprograms✓✓

• IterativeimprovementofSMSsassupportandriskmanagementplan✓

• Alignmentwithcountrymhealthstrategyforscale-up

• StakeholderengagementtoextendMAbeyond63daysinpublicsector

• StakeholderengagementtoapproveimplementationofLSUPTinpublic

sector

• Acknowledgements:Exelgyn,fieldworkers,participants

• Funding:SAAF,WHO,IPAS

THANKYOUDeborah.constant@uct.ac.za