Browsing by Author "Cleeve, Amanda"

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    Abortion as agentive action: reproductive agency among young women seeking post-abortion care in Uganda.
    (An International Journal for Research, Intervention and Care, 2017-11) Cleeve, Amanda; Faxelid, Elisabeth; Nalwadda, Gorette; Klingberg-Allvin, Marie
    Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one's body and future. Women's experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.
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    Adherence to modern contraceptives among female refugee adolescents in northern Uganda: A prospective single cohort study
    (A prospective single cohort study, 2022) Bakesiima, Ritah; Gemzell-Danielsson, Kristina; Beyeza-Kashesya, Jolly; Ayebare, Elizabeth; Cleeve, Amanda; Larsson, Elin C.; Nabirye, Rose C.
    Background: Contraceptive adherence is the current and consistent use of a contraceptive method as prescribed by a health worker or family planning provider so as to prevent pregnancy. Globally, adherence is lowest among adolescents. This has greatly contributed to the high burden of adolescent pregnancies. Adherence and reasons for discontinuation among refugee adolescents are poorly understood. The aim of this study was to determine the rates and predictors of adherence to modern contraceptives among female refugee adolescents in northern Uganda. Methods: A prospective single cohort study, nested into a randomised controlled trial (RCT) assessing the effect of peer counselling on acceptance of modern contraceptives. The RCT was conducted among female refugee adolescents in Palabek refugee settlement, northern Uganda. The study involved 272 new starters of modern contraceptives who were followed up for six months from May 2019 to January 2020. The outcome was measured at one, three and six months after receiving a contraceptive method. Data was analysed using STATA version 14.0. Results: Adherence rates were low and reduced over time. By the end of the six months, only 44% of the participants were using a contraceptive method. The commonest reasons for non-adherence were side effects and partner prohibition. Participants using long acting reversible contraceptives (LARC) were more likely to adhere compared to those who were using short acting reversible contraceptives (SARC) (OR: 3.37, 95% CI: 1.914-5.937, p=<0.001). There was no difference in adherence between participants who received peer counselling and those who received routine counselling. Conclusion: Adherence to modern contraceptives was low, leaving adolescents at risk of unintended pregnancies. Participants using LARC were more likely to adhere than those using SARC. Interventions addressing fear of side effects and partner prohibition should be studied and implemented to enable adherence to modern contraceptives
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    Effectiveness of Early versus Standard Intrauterine Contraception following Medical 2 Management of First Trimester Incomplete Abortions: A Non-Inferiority Open-Label 3 Randomized Control Trial in central Uganda
    (2025) Kayiga, Herbert; Looft-Trägårdh, Emelie; Kakaire, Othman; Cleeve, Amanda; Rujumba, Joseph; Sekikubo, Musa; Tumwesigye, Nazarius M.; Byamugisha, Josaphat; Gemzell-Danielsson, Kristina
    Background: With paucity of information on ideal timing for intrauterine contraception placement, we set out to determine the effectiveness of early insertion (within one week) versus standard insertion (two-four weeks) of intrauterine contraception after medical management of first trimester incomplete abortions in central Uganda. Methods: In a multicenter non-inferiority trial at five public health facilities in central Uganda, 1,050 women with first trimester incomplete abortions managed by sublingual misoprostol, were recruited upon giving informed consent. After selecting either Copper or Levonorgestrel intrauterine devices (IUDs), participants were randomly assigned to early or standard insertion arms in a ratio of 1:1. The primary outcome was IUD expulsion rates at six-months. The non-inferiority margin was set at 5% for the upper limit of the confidence interval (CI) for the absolute risk difference. The trial was registered at ClinicalTrials.gov NCT05343546. Findings: Between 8th July 2023 to 31st May 2024, 528 (50·3%) participants were assigned to early and 522 (49·7%) participants to standard insertion arms. About 531 (50·6%) participants chose Levonorgestrel IUDs, 489 (46·6%) participants chose copper IUDs, while 30 (2·9%) participants opted against IUDs. In an intention-to-treat analysis, expulsion occurred in 23 (4·4%) of 528 participants in the early insertion arm and in 24 (4·6%) of 522 participants in the standard arm; Adjusted Risk Difference (standard-early) was -0·00006 (95% CI: -0·0008 to 0·00066, p = 0·93). No serious adverse events occurred in both arms. The IUD continuation rates at six-months were 91·1% in the early and 90·2% in the standard insertion arms. Interpretation: Early IUD insertion after medical treatment of first trimester incomplete abortions was non-inferior to standard IUD insertion with respect to expulsion. Early IUD insertion may help to prevent unintended pregnancies.
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    Healthcare providers’ perceptions on post abortion intrauterine contraception: A qualitative study in central Uganda
    (PloS one, 2024) Kayiga, Herbert; Looft-Tragårdh, Emelie; Cleeve, Amanda; Kakaire, Othman; Tumwesigye, Nazarius M.; Byamugisha, Josaphat; Gemzell-Danielsson, Kristina
    Despite access to post abortion intrauterine contraception, the uptake of Intrauterine devices (IUDs) in Uganda remains low. Whether the perceptions of healthcare providers towards IUDs have a role in the provision of post abortion IUDs remains unclear. We explored perceptions on post abortion IUD provision among healthcare providers in Uganda, focusing on barriers and facilitators in regards to provision and uptake. Methods Between 1st August 2022 and 30th September 2022, forty-five in-depth interviews were conducted among healthcare providers of different cadres at sixteen public health facilities in central Uganda. We used the case study design to explore the healthcare providers’ perceptions. The interviews were primarily to help us understand the perceptions of healthcare providers towards IUDs. All interviews were audio-recorded and transcribed verbatim. Themes were identified using the conventional inductive content analysis. Results From the analysis, three themes emerged. Theme one covered health system related barriers in regards to IUD provision such as healthcare providers’ and health facility challenges. The second theme focused on the challenges in post abortion contraceptive counselling focusing on IUDs. The third theme covered the motivating factors and participants’ views on how to scale up IUD uptake and provision within post abortion care in Uganda. We found that lack of appropriate knowledge and skills on IUD provision, and heavy workloads, negatively impacted IUD provision. Inadequate facilities, IUD stock-outs, and minimal community sensitization also limited the utilization of IUDs. Furthermore, language barriers, community misconceptions around IUDs, long travel distances to the health facility, and partner refusal, contributed to the low uptake of post abortion IUDs. To address the identified barriers and scale up post abortion IUD provision, participants recommended addressing health system barriers, regular in-service refresher trainings, mentoring and supervision. They emphasized the importance of addressing contraceptive misconceptions and men’s opposition to IUDs through community sensitization. Conclusion In this study we identified several barriers to post abortion IUD provision, highlighting an urgent need to address health system barriers including healthcare providers’ skills and knowledge gaps, supply chain challenges, and to ensure that facilities are conducive to quality contraceptive counselling. Provision of on-job refresher trainings, mentoring and supervision, are key motivators that can be utilized in supporting healthcare providers towards post abortion IUD provision. To further increase uptake, efforts are needed to dispel contraceptive myths and misconceptions at the community level.
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    Modern contraceptive use among female refugee adolescents in northern Uganda: prevalence and associated factors
    (Reproductive Health, 2020) Bakesiima, Ritah; Cleeve, Amanda; Larsson, Elin; Tumwine, James K.; Ndeezi, Grace; Danielsson, Kristina G.; Nabirye, Rose C.; Kashesya, Jolly B.
    Background: Adolescent pregnancies are persistently high among refugees. The pregnancies have been attributed to low contraceptive use in this population. The aim of this study was to determine the prevalence and factors associated with modern contraceptive use among female refugee adolescents in northern Uganda. Methods: This was a cross sectional study using both descriptive and analytical techniques. The study was carried out in Palabek refugee settlement in Northern Uganda from May to July 2019. A total of 839 refugee adolescents who were sexually active or in-union were consecutively enrolled. Interviewer administered questionnaires were used for data collection. Results: Modern contraceptive prevalence was 8.7% (95% CI: 7.0 to 10.8). The injectable was the most commonly used modern contraceptive method [42.5% (95% CI: 31.5 to 54.3)], and most of the participants had used the contraceptives for 6 months or less (59.7%). Reasons for not using modern contraceptives included fear of side effects (39.3%), partner prohibition (16.4%), and the desire to become pregnant (7.0%). Participants who were married (OR = 0.11, 95% CI: 0.04 to 0.35, p < 0.001), cohabiting (OR = 0.43, 95% CI: 0.20 to 0.93, p = 0.032) or having an older partner (OR = 0.93, 95% CI: 0.86 to 0.99, p = 0.046) were less likely to use modern contraceptives. Conclusion: Modern contraceptive use among female refugee adolescents was very low, and few reported a desire to become pregnant, leaving them vulnerable to unplanned pregnancies. Least likely to use modern contraceptives were participants who were married/cohabiting and those having older partners implying a gender power imbalance in fertility decision making. There is an urgent need for innovations to address the gender and power imbalances within relationships, which could shape fertility decision-making and increase modern contraceptive use among refugee adolescents.
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    Uptake of Intrauterine Contraception after Medical Management of First Trimester Incomplete Abortion : A Cross-sectional study in central Uganda
    (2024) Kayiga, Herbert; Looft-Trägårdh, Emelie; Cleeve, Amanda; Kakaire, Othman; Tumwesigye, Nazarius M.; Sekikubo, Musa; Rujumba, Joseph; Gemzell- Danielsson, Kristina; Byamugisha, Josaphat
    Although intrauterine devices (IUDs) are readily available in Uganda, their utilization remains low, including within post abortion care. The level and factors associated with uptake of post abortion IUDs are not well documented. We set out to determine the uptake and factors associated with uptake of post abortion IUDs after medical management of first trimester incomplete abortions in central Uganda. Methods Between February 2023 and September 2023, we conducted a cross-sectional study among women aged 15 to 49 years, who expressed interest in initiating post abortion intrauterine contraception and were managed with Misoprostol for first trimester incomplete abortions at five health facilities in central Uganda. Healthcare providers received extensive training in post abortion contraceptive counselling and service provision. Data from 650 participants were collected using interviewer administered questionnaires. The primary outcome was uptake of post abortion IUDs, defined as the actual insertion of the post abortion IUDs. Data were collected during a post abortion follow up visit. The determinants of post abortion IUD uptake were assessed using the modified poisson regression. Results The proportion of women who took up IUDs after medical management of first trimester abortion, was 370/650 (56.9%). Among the other available contraceptive choices, 121(18.6%) women opted for injectable Depo-Provera (DMPA), 116(17.9%) women opted for implants, 35(5.4%) women opted for oral contraceptive pills, five (0.8%) of the women opted for condoms, and three (0.5%) women for periodic abstinence. The mean age of the participants was (27.3 ± SD 1.8) years. A high proportion of the women in the study were; Catholics (32.3%), unemployed (52.6%), cohabiting with their partners (84.0%) and had given birth to 2-3 children (38.5%). A high proportion (56%) of IUD users, opted for the copper IUDs. The post abortion IUD uptake was independently associated with religion- being a Pentecostal (Adjusted PR=2.49, CI= (1.19-5.23), p-value=0.016), monthly earning > one million Ugx (270 USD) (Adjusted PR=1.88, CI= (1.44-2.46), p-value<0.001), and staying <5 kilometres from the health facility (Adjusted PR=1.34, CI= (1.04-1.72), p-value=0.023). Women who were not cohabiting with their partners, were less likely to choose IUDs (Adjusted PR=0.59, CI= (0.44-0.79), p-value=0.001). Conclusion The uptake of IUDs among post abortion women was nearly 60% emphasizing the potential impacts of integrated contraceptive services in Post abortion care. The impact of comprehensive and updated training on post abortion contraceptive counselling is vital on the uptake of IUDs. Regardless of sociodemographic status, women seeking post abortion care in Uganda should be provided with high-quality integrated services by trained providers offering a range of contraceptive methods. Such efforts may not only prevent unintended pregnancies but also improve health equity across the country.