Establishing effective postnatal contraception is essential for HIV-seropositive women to avoid the risk of unwanted pregnancy and minimise HIV transmission to HIV-seronegative partners. The authors describe their experience of providing postnatal contraception to HIV-seropositive women who attend a community-based integrated sexual health clinic.
The authors performed a retrospective case note review of all women who received care for HIV in pregnancy to term at their clinic from September 2000 to October 2010.
A total of 107 pregnancies among 95 women were eligible for review. Attendance for contraceptive advice within 4 weeks of delivery occurred in 82/107 (77%) pregnancies. Depo-Provera® was prescribed in 21 (21/82, 26%) cases; an intrauterine contraceptive was arranged in 22/82 (27%) cases and sterilisation had occurred as part of a Caesarean delivery in 10/82 (12%) cases. In seven women who discontinued antiretroviral therapy at delivery one subdermal implant was fitted and the combined contraceptive pill was prescribed six times. In 17/82 (21%) cases women opted to use condoms alone. Attendance for postpartum contraceptive advice was missed following 21/107 (20%) pregnancies.
Uptake of a second contraceptive method in addition to condoms is high among women who attend clinic for contraceptive advice in the immediate postnatal period. However, 20% of women did not attend and their contraceptive choices remain unknown. These women are at risk of unwanted pregnancy and transmission of HIV to seronegative partners if appropriate contraceptive methods are not re-established postpartum.
A ‘fast-track’ referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh.
Case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. Main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates.
Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p=0.003), less likely to live in an area of deprivation (p=0.045) and were significantly more likely to have attended the FPC in the past (p<0.0001). Most attenders (90%; n=113) proceeded to have an intrauterine method inserted; 57% (n=64) chose the levonorgestrel intrauterine system and 43% (n=49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0–54) days. Of those women (n=55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection.
Only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.
Women seeking abortion services need to access services in a timely fashion. Quick and appropriate referrals to abortion providers are critical to this process.
The objective of this study was to determine the quality and quantity of referrals for abortion services from reproductive health care facilities that do not provide abortion services. USA states were ranked by restrictiveness of abortion, and a simulated patient made calls to the five most and six least restrictive states. Referrals were considered direct if the name or telephone number of a facility that provided abortion services was given; indirect when Planned Parenthood was suggested without additional details; and inappropriate if the referral did not provide abortion services.
Of 142 calls, 77 (52.4%) were made to least restrictive states and 62 (45.8%) were made to most restrictive states. Among all calls, even after prompting staff members for a referral, 45.8% resulted in a direct referral, 19.0% resulted in an indirect referral, 8.5% resulted in an inappropriate referral and 26.8% resulted in no referral. Facilities in least restrictive states were significantly more likely to provide unprompted direct referrals (p=0.006) and significantly less likely to provide no referral (p<0.001) than facilities in most restrictive states, though these differences disappeared after prompting the staff member to provide a referral.
A simulated patient received a direct referral for abortion services less than half the time, even after prompting a staff member to provide one. All facilities providing women's health care should have appropriate referrals readily available for patients seeking abortion services.
Little is known about the ethnic differences in disease presentation of uterine cancer in New Zealand women. The objectives of this study were two-fold: (1) to estimate the incidence and mortality of uterine cancer among women in New Zealand and (2) to examine the association of ethnicity and socioeconomic status with tumour stage and grade, at presentation of uterine cancer.
Retrospective survey of cancer cases identified from the New Zealand Cancer Registry. The authors analysed all 3203 uterine cancer cases registered with the New Zealand Cancer Registry during the period 1 January 1997 to 31 December 2006. Ethnic groups were defined based on the self-identified ethnicity recorded on the cancer registry: Ma–ori, Pacific and non-M–aori non-Pacific women. Socioeconomic status was categorised as quintiles of the New Zealand Deprivation Index 2006. The mortality to incidence ratio was used as a measure of prognosis. Logistic regression was used to estimate age, ethnic and deprivation adjusted odds ratios (ORs) and 95% confidence intervals (CIs).
Pacific and M–aori women have higher incidence (32.4 and 17.7 per 100 000 women, respectively) and mortality rates of uterine cancer (12.1 and 7.4 per 100 000 women, respectively). Women in the most deprived areas are more likely to present with an advanced stage of uterine cancer (OR 1.64, 95% CI 1.09–2.48). M–aori and Pacific women are less likely to present with well-differentiated tumours (OR 0.69, 95% CI 0.52–0.92 and OR 0.72, 95% CI 0.52–0.99, respectively).
M–aori and Pacific women, and those from lower socioeconomic areas, are more likely to present with advanced uterine cancer.
"PTP": three letters scrawled in the tattered notebook that served as her medical record. What did it mean? For me, it explained why my previous patient was crying inconsolably onto a nurse's shoulder. For her it signified far more: another mouth to feed, another nervous wait for an HIV test, a shortage of blankets, an unwanted shift in her world. Clinic over, I went outside and gazed at the zig-zag skyline of the mountains. Pregnancy test positive: one of those deceptively simple acronyms that tames the complexity of our patients' lives into something writeable, something understandable, something medical.
I was on my elective in Lesotho, a country about the size of Wales and entirely surrounded by South Africa. It was late June, winter in Lesotho, a season of glaringly bright days and densely cold nights. That day I was working at an ‘outreach clinic’ run by Maluti Adventist Hospital: each...]]>
To explore awareness of and participation in cervical screening services in women from Poland, Slovakia and Romania living in London, UK.
Three qualitative studies were carried out in London in 2008–2009: an interview study of professionals working with Central and Eastern European migrants (n=11); a focus group study including three Polish, one Slovak and one Romanian focus group; and an interview study of Polish (n=11), Slovak (n=7) and Romanian (n=2) women.
Awareness of the cervical screening programme was good, but understanding of the purpose of screening was sometimes limited. Some women were fully engaged with the UK screening programme; others used screening both in the UK and their countries of origin; and a third group only had screening in their home countries. Women welcomed the fact that screening is free and that reminders are sent, but some were concerned about the screening interval and the age of the first invitation.
Migrant women from Poland, Slovakia and Romania living in London vary in their level of participation in the National Health Service Cervical Screening Programme. More needs to be done to address concerns regarding screening services, and to ensure that language is not a barrier to participation.
The study aim was to examine whether exposure to intimate partner violence (IPV) was associated with reversible contraceptive use in ever-pregnant partnered women. The authors conducted a longitudinal panel study in León municipality, Nicaragua. At baseline (2002–2003), 478 pregnant women were interviewed and 398 were available for questioning about contraceptive use 40–47 months after childbirth. IPV was assessed at baseline and follow-up, with women classified as never abused, ending abuse, continued abuse or new abuse. Reversible contraceptive use was defined as women using any form of contraception apart from sterilisation. Adjusted odds ratios (AORs) were used to assess the association between reversible contraceptive use, IPV patterns and IPV exposures at follow-up.
Eighty percent of the women were not pregnant and with a partner at follow-up. Half were using reversible contraceptives and 28% were sterilised. Women exposed to a continued abuse pattern (AOR 2.50, 95% CI 1.04–5.99), and those exposed to emotional (AOR 2.80, 95% CI 1.32–5.95), physical (AOR 3.60, 95% CI 1.15–11.10) or any IPV at follow-up (AOR 2.59, 95% CI 1.24–5.40) had higher odds of reversible contraceptive use than those not exposed, even after adjusting for demographic factors. No significant differences in the type of reversible contraceptive used were found between women exposed or not to IPV.
IPV exposure was associated with more reversible contraceptive use. Abuse inquiring at health facilities providing contraceptives should be implemented to identify women exposed to IPV and provide adequate support.
The immortal words "Yes, We Can" will forever be ingrained in the memory of anyone following the United States (US) presidency campaign stretching from early 2007 to late 2008. When President Barack Obama was inaugurated into office, the whole world knew it was a historic moment. He had easily defeated Republican rival John McCain to become the first black President of the USA. Moreover, the world was now ready for change. And Obama convinced the US people that he could deliver, with those words: "Yes, We Can". However, after completing his first year in office in 2009, the optimism had drained away and critics have been questioning whether Obama's well-crafted speeches and charisma have any true substance. Domestically, his presidency has been dominated by his controversial attempts to reform the US health care system. Internationally, his policies towards Afghanistan, nuclear disarmament, the debt crisis and climate change have been...]]>
The aim of the study was to develop and validate measures of awareness of symptoms and risk factors for ovarian and cervical cancer (Ovarian and Cervical Cancer Awareness Measures).
Potentially relevant items were extracted from the literature and generated by experts. Four validation studies were carried out to establish reliability and validity. Women aged 21–67 years (n=146) and ovarian and cervical cancer experts (n=32) were included in the studies. Internal reliability was assessed psychometrically. Test-retest reliability was assessed over a 1-week interval. To establish construct validity, Cancer Awareness Measure (CAM) scores of cancer experts were compared with equally well-educated comparison groups. Sensitivity to change was tested by randomly assigning participants to read either a leaflet giving information about ovarian/cervical cancer or a leaflet with control information, and then completing the ovarian/cervical CAM.
Internal reliability (Cronbach's α=0.88 for the ovarian CAM and α=0.84 for the cervical CAM) and test-retest reliability (r=0.84 and r=0.77 for the ovarian and cervical CAMs, respectively) were both high. Validity was demonstrated with cancer experts achieving higher scores than controls [ovarian CAM: t(36)= –5.6, p<0.001; cervical CAM: t(38)= –3.7, p=0.001], and volunteers who were randomised to read a cancer leaflet scored higher than those who received a control leaflet [ovarian CAM: t(49)=7.5, p<0.001; cervical CAM: t(48)= –5.5, p<0.001].
This study demonstrates the psychometric properties of the ovarian and cervical CAMs and supports their utility in assessing ovarian and cervical cancer awareness in the general population.
The Standard Days Method® (SDM) is a fertility awareness-based method of family planning that helps users to identify the fertile days of the reproductive cycle (Days 8–19). To prevent pregnancy users avoid unprotected sexual intercourse during these days. A cross-sectional community-based study was conducted from December 2007 to June 2008 in four operational areas of Pathfinder International Ethiopia. A total of 184 SDM users were included in the study. Quantitative and qualitative methods of data collection were used. The aim of the study was to examine the experience of introducing the SDM at community level in Ethiopia.
Of the 184 participants, 80.4% were still using the SDM at the time of the survey, with 35% having used it for between 6 and 12 months, while 42% had used it for more than a year. The majority (83%) knew that a woman is most likely to conceive halfway through her menstrual cycle, and nearly 91% correctly said that the SDM does not confer protection from sexually transmitted infections/AIDS. A substantial majority (75%) had correctly identified what each colour-coded bead represents in the CycleBeads®, and an aggregate of 90.5% of women practised all the elements of correct use.
This study demonstrates the importance of the SDM in increasing the availability and accessibility of family planning, and the potential to improve family planning method choice and method mix by expanding use of the SDM.
To examine the long-term effectiveness and continuation of the Standard Days Method (SDM)®, a fertility awareness-based method of family planning that identifies Days 8–19 (inclusive) of the cycle as the fertile window. On these days users avoid unprotected sexual intercourse to prevent pregnancy. The method works best for women with cycles that are usually in the range of 26–32 days, which is an important reason for method discontinuation in the first year of use. The authors determine if this continues to be an issue in the second and third years of method use.
Participants in an earlier efficacy study (478 women in three countries) and method introduction studies (1181 women in four countries) were followed for 2 years beyond the original 1-year study period, to determine their continued use of the method, intended and unintended pregnancies, and reasons for discontinuation. Life-tables were used to approximate typical use pregnancy rates.
The method continues to be effective in the second and third years of use, and compares favourably to other user-directed family planning methods. Women with no more than two cycles outside the 26–32-day range within a year are likely to continue having cycles within this range.
Women who complete the first year of SDM use are likely to continue to be able to use the method successfully and effectively. The method presents a viable longer-term option for women who prefer this approach to family planning.