Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care

Objective

To characterize prenatal and delivery care in an urban African setting.

Methods

The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector.

Results

From June 1, 2007, to January 31, 2010, 115 552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23 weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95 663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111 108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112 813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38 weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000 g (IQR 2700-3300 g).

Conclusion

The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.     

Knowledge about emergency contraception among family-planning providers in urban Ghana

Objective

To assess the theoretical and practical knowledge about emergency contraception (EC) among family-planning (FP) providers in Ghana and to examine the association between FP providers’ theoretical and practical knowledge.

Methods

Data on 600 FP providers were collected through a census of facilities offering FP services in Kumasi, Ghana, in 2008. Nested linear multivariate regression analysis was used to identify sociodemographic, facility-related, and work-related variables associated with FP providers’ theoretical and practical knowledge about EC.

Results

On average, FP providers gave 4.1 correct answers to the 11 questions assessing theoretical knowledge and 5.6 correct answers to the 8 questions assessing their practical ability to provide EC. The FP providers seemed to learn provision-related aspects through practice without having a particularly good theoretical knowledge on EC as a contraceptive method. The health sector in which FP providers worked, their education and having received EC-specific training, the number of services offered, and the number of women seen during a week were all significant correlates of both theoretical and practical knowledge about EC. The 2 knowledge domains were significantly and positively associated.

Conclusion

There is need to improve knowledge about EC among FP providers in Ghana through in-service training.     

A qualitative study of the information needs of premenopausal women with breast cancer in terms of contraception, sexuality, early menopause, and fertility

Objectives

To evaluate the information needed and received by premenopausal Turkish women with breast cancer regarding contraception, early menopause, infertility, fertility preservation, and sexuality.

Methods

A qualitative exploratory methodology was used whereby an interviewer met on 2 occasions with women with breast cancer. The participants—who were recruited from the oncology clinic of Adnan Menderes University Hospital, Ayd?n, Turkey—were premenopausal, younger than 50 years of age, and had been diagnosed with breast cancer within the past year. Raw data were sorted under themes.

Results

Premenopausal women with breast cancer received insufficient counseling on contraception, early menopause, infertility, fertility preservation, and sexuality, despite their willingness to receive information.

Conclusion

In Turkey, premenopausal women with breast cancer should receive comprehensive information and counseling from oncology staff on the issues studied. The present study may guide future research on this topic.     

Breastfeeding and contraception use among women with unplanned pregnancies less than 2 years after delivery

Objective

To examine breastfeeding and contraceptive use after the lactational amenorrhea method (LAM) criteria were no longer met.

Methods

Two hundred and thirty-three parous Egyptian women with unplanned pregnancies less than 2 years after delivery completed a questionnaire examining breastfeeding practice and contraceptive use.

Results

The majority of women (81.5%) with unplanned pregnancies within 2 years of delivery were breastfeeding at conception. Of these women, 36.3% had used a method of contraception other than LAM compared with 60.5% of women who had weaned (P < 0.05). Among the breastfeeding women, 61.2% failed to use contraception because they believed breastfeeding would prevent pregnancy.

Conclusion

Breastfeeding women with unplanned pregnancies were less likely to have used contraception than women who had weaned, suggesting that prolonged breastfeeding contributes to unmet contraceptive need.     

Anticoncepción posparto en mujeres con riesgo de exclusión social

Objective

Improve birth control rates in women from vulnerable populations, space time out between pregnancies and reduce the rate of abortions.

Material and methods

We gave 90 pregnant women at risk of social exclusion an appointment for a postpartum check- up a month and a half after their expected due date, with a SMS reminder 48 hours before the appointment and a phone number in case they failed to make the appointment. We strive to implement long-term methods on the day of appointment.

Results

92% attended the postnatal visit. The overall rate of contraception was 86%, 68% were long-term methods: subdermal implants and IUDs.

Conclusion

Consultation with postpartum women from disadvantaged social groups can be very useful to facilitate contraceptive methods which are safe, effective and long-lasting. Flexibility and agility in the implementation of the methods are essential.     

Emergency contraception in the context of marriage in Upper Egypt

Objective

To explore the degree of knowledge, perception, and practice of emergency contraception (EC) within marital relations in Egypt.

Methods

The present study was a pilot cross-sectional survey. Eligible participants were randomly selected from 4 governorates in Upper Egypt. A questionnaire was designed by the investigators and administered to an unselected sample of healthcare providers and potential users of EC. The questionnaire collected information in 4 domains: demographics; knowledge about EC; attitudes toward EC; and practice of EC in Egypt.

Results

In total, 240 healthcare providers and 60 potential users of EC completed the questionnaire. Approximately 85% of healthcare providers and 30% of potential users had heard about EC. A similar proportion of study participants said that EC methods are needed. Only 32.7% of healthcare providers and very few potential users had actually used EC.

Conclusion

There is a need for EC in Egypt. However, a big gap in knowledge leads to nonuse or incorrect use of EC and negative attitude toward it. If health service planners and policy makers could fill this gap, a considerable decline in the prevalence of unwanted pregnancy may be achieved by using EC.     

Assessing the extent of provision of comprehensive medical care management for female sexual assault patients in US hospital emergency departments

Objective

To describe medical services provided to sexual assault patients in US emergency departments and to identify the percentage of hospitals always providing the 10 elements of comprehensive medical care management (CMCM).

Methods

A cross-sectional study was conducted in a national sample of US hospitals. A 26-item telephone survey assessed provision of services to sexual assault survivors in accordance with CMCM. Management included acute medical care comprising history and physical examination; acute and long-term rape crisis counseling; STI testing and prophylaxis; emergency contraception counseling and provision; and HIV testing and prophylaxis. The primary outcome was extent of provision of these elements.

Results

Overall, 582 emergency departments responded to the survey. The following components of CMCM were provided: acute medical care (582 [100.0%]); rape crisis counseling (234 [40.2%]); STI management (448 [77.0%]); emergency contraception (351 [60.3%]); and HIV management (380 [65.3%]). Only 101 (17.4%) hospitals provided all 10 elements of CMCM.

Conclusion

Less than one-fifth of US hospitals provide comprehensive services to sexual assault patients. A national program incorporating clinical guidelines, checklists, and funding for sexual assault forensic/nurse examiner programs could improve the standard of care provided in emergency departments—the primary point of contact for acute care of sexual assault survivors.     

Where there is no anesthetist - increasing capacity for emergency obstetric care in rural India: An evaluation of a pilot program to train general doctors

Objective

The lack of anesthesia providers in rural public sector hospitals is a significant barrier to providing emergency obstetric care. In 2006, the state of Gujarat initiated the Life Saving Anesthetic Skills (LSAS) for Emergency Obstetric Care (EmOC) training program for medical offers (MOs). We evaluated the trained MOs’ experience of the program, and identified factors leading to post-training performance.

Methods

The sample was chosen to equally represent performing and nonperforming LSAS-trained MOs using purposive sampling qualitative interviews with trainees across Gujarat (n = 14). Data on facility preparedness and monthly case load were also collected.

Results

Being posted with a specialist anesthesiologist and with a cooperative EmOC provider increased the likelihood that the MOs would provide anesthesia. MOs who did not provide anesthesia were more likely to have been posted with a nonperforming or uncooperative EmOC provider and were more likely to have low confidence in their ability to provide anesthesia. Facilities were found to be under prepared to tackle emergency obstetric procedures.

Conclusion

Program managers should consider extending the duration of the program and placing more emphasis on practical training. Posting doctors with cooperative and performing EmOC providers will significantly improve the effectiveness of the program. A separate team of program managers who plan, monitor, and solve the problems reported by the trained MOs would further enhance the success of scaling up the training program.     

Combined contraceptive ring versus combined oral contraceptive (30-μg ethinylestradiol and 3-mg drospirenone)

Objectives

To compare the adverse effects, cycle control, and metabolic effects of NuvaRing and a combined oral contraceptive (COC).

Methods

Women seeking contraception received NuvaRing (n = 300) or a COC (n = 300) for 12 cycles in a randomized, open-label trial.

Results

The total number of women with adverse effects did not differ significantly between the 2 groups. Leucorrhea, vaginitis, decreased libido, and ring-related problems were more common with NuvaRing, whereas weight increase, acne, and emotional lability were more common with the COC. Breakthrough bleeding occurred in 11.3% of women receiving NuvaRing and in 14.7% of women receiving the COC; 2.1% and 2.9% of women, respectively, had no withdrawal bleeding. Differences in blood pressure, blood sugar levels, lipid profile, liver enzyme activity, and anticoagulant activity were not statistically significant, with the exception of low-density lipoprotein levels measured at 6 and 12 months, which were significantly lower in the NuvaRing group than in the COC group.

Conclusions

NuvaRing is a good alternative to a COC. It is associated with a slightly reduced incidence of breakthrough bleeding and there were no clinically relevant adverse effects or changes in blood pressure, blood sugar levels, lipid profile, or anticoagulant activity when compared with the COC.     

Emergency obstetric surgery by non-physician clinicians in Tanzania

Objective

To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC.

Methods

All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined.

Results

Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma.

Conclusion

AMOs carried most of the burden of life-saving EmOC—particularly cesarean deliveries—in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%.     

Equivalence of the 3-month and 28-day formulations of triptorelin with regard to achievement and maintenance of medical castration in women with endometriosis

Objective

The present study aims at demonstrating the equivalence of the 28-day and 3-month formulations of triptorelin SR (sustained release) in terms of percentage of patients achieving castration levels of estradiol (≤50 pg/mL) 84 days after treatment initiation.

Design

A phase II, prospective, randomized, multicenter, open study was conducted in two parallel groups of women with endometriosis.

Setting

Academic hospitals.

Patient(s)

Seventy-two women with endometriosis. were treated with a single intramuscular injection of 3-month triptorelin SR, and 74 patients were treated with one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months.

Intervention(s)

As part of two parallel treatment groups, 72 women were given a single intramuscular injection of 3-month triptorelin SR, and 74 women were given one intramuscular injection of 28-day triptorelin SR every 28 days for 3 months.

Main outcome measure(s)

Percentage of patients achieving castration levels of estradiol at the end of the treatment period.

Result(s)

Patients participated in the study until resumption of menses. Ninety-seven percent of patients given the 3-month formulation and 94% of those given the 28-day formulation were in a state of medical castration on day 84. The mean time to achieve castration was shorter for the 3-month formulation, and the duration of castration was significantly longer. The FSH and LH parameters were comparable, though not always identical.

Conclusion(s)

The pharmacodynamic effects of the Decapeptyl SR 3-month formulation are equivalent to those of the 28-day formulation. The 3-month formulation provides the added advantage of a longer maintenance of medical castration in women who have endometriosis.     

Profiles of women presenting for abortions in Singapore: focus on teenage abortions and late abortions

Objective

Teenage abortions predispose women to adverse pregnancy outcomes in subsequent pregnancies such as anemia, stillbirths, preterm deliveries and low birth weight babies. We aim to profile the women presenting for abortions in our institution and determine risk factors for late presentation for abortions.

Study design

In this retrospective cohort study, all women who underwent an abortion at the National University Hospital, Singapore, from 2005 to 2009 were recruited. Data was obtained from a prepared questionnaire during the mandatory pre-abortion counseling sessions. Profiles of women aged <20 years were compared with those ≥20 years old using Chi-square test if the assumptions for Chi-square test were met; otherwise, Fisher's exact test was carried out. Logistic regression was used to investigate the risk factors for second trimester termination of pregnancy.

Results

2109 women presented for induced abortions, of which 1998 had single abortion throughout the course of the study. The mean age of women with single abortion was 29.1 years (sd 7). In the group of women with single abortion, 182 (9.1%) were teenage abortions. In contrast to women ≥20 years of age, pregnant teenagers were more likely not to have used any contraception (51.1% vs. 25.2%) and more likely to present late for abortions (39.6% vs. 15.9%). Other risk factors for late presentation for abortions include Malay ethnicity, singlehood, nulliparity and lack of prior usage of contraception.

Conclusion

Teenagers are more likely to have no prior contraceptive usage and to present late for abortions. Lack of proper sexual education and awareness of contraceptive measures may have a major contributory factor to such a trend in teenage abortions. Recommendations have been made in order to curb this societal problem.     

Bone mineral density in women using the subdermal contraceptive implant Implanon for at least 2 years

Objective

To compare the effect of the long-term use of a subdermal single-rod contraceptive implant on bone mineral density (BMD) between users and a control group.

Methods

In this cross-sectional study, BMD was measured at the lumbar spine, femur, and distal radius and ulna in 100 Thai women of reproductive age, 50 who had used the Implanon implant for contraception for at least 2 years and 50 controls.

Results

Ethnicity, age, age at menarche, parity, menstrual pattern, and body mass index were similar in the 2 groups. The mean duration of Implanon use was 32.8 ± 6.3 months. Although the prevalence of osteoporosis was rare at all sites in both groups, the Implanon users had a significantly lower BMD at the distal radius and ulna than the controls.

Conclusion

The long-term use of Implanon seemed to have a negative impact on the mineral density of the distal radius and ulna.     

Fertility desires and the feasibility of contraception counseling among genital fistula patients in eastern Democratic Republic of the Congo

Objective

To determine the fertility and contraceptive desires of genital fistula patients in eastern Democratic Republic of the Congo (DRC) and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use.

Methods

Group contraceptive counseling was offered to fistula patients at HEAL Africa Hospital between February and May 2010. Fertility desires and contraceptive knowledge were assessed via verbally administered questionnaires before and after counseling, and use of modern contraceptive methods was tracked.

Results

Of the 61 participants, 22/34 (64.7%) of those who desired children wanted to wait at least 1 year after repair before attempting pregnancy. Overall, 31/58 (53.4%) women had heard of birth control, although only 15 (24.6%) knew any specific methods, and none had ever used contraception. After counseling, all participants could recall 1 or more methods. Of the 25 participants discharged over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern method of contraception.

Conclusion

Desire for contraception and birth spacing among women with fistula is significant. Basic group contraception counseling and access are feasible and lead to increased contraceptive knowledge and use.     

The rapid biophysical profile for early intrapartum fetal well-being assessment

Objective

To determine the efficacy of the rapid biophysical profile (rBPP), which uses sound-provoked, ultrasonographically detected fetal movement and amniotic fluid index, for early intrapartum fetal well-being assessment and prediction of adverse perinatal outcomes.

Methods

Rapid BPP was performed in 330 women admitted to the labor unit of Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand, from January 2005 to July 2005. Those who were delivered later than 24 h after the rBPP, or who required emergency cesarean section because of placenta previa, abruptio placentae or prolapsed cord were to be excluded. Perinatal outcomes were prospectively assessed and recorded for subsequent analysis. The predicting accuracy of rBPP was calculated according to poor outcomes, which included fetal distress, low Apgar score, admission to the neonatal intensive care unit and perinatal death.

Results

Among the 330 pregnancies, there were 6 adverse perinatal outcomes (1.8%). The rBPP had a sensitivity of 50.0%, a specificity of 99.07%, a positive predictive value of 50.0%, a negative predictive value of 99.07% and an accuracy of 98.18%.

Conclusion

With its simplicity, low cost and high specificity but its low sensitivity and low negative predictive value, the rBPP may be used as a back-up test to confirm fetal well-being during the early intrapartum period in developing countries.     

Expression of the Wnt antagonist Dickkopf-3 is associated with prognostic clinicopathologic characteristics and impairs proliferation and invasion in endometrial cancer

Objective

Emerging evidence implicates the Wnt antagonist Dickkopf-3 (Dkk3) as a tumor suppressor and potential biomarker in solid tumors. We investigated whether Dkk3 plays an important role in the carcinogenesis of endometrial cancer (EC).

Methods

We analyzed Dkk3 mRNA expression via real-time RT-PCR in twenty-seven human primary EC tissues, and six matched normal endometrial controls. Dkk3 levels were correlated with various clinicopathologic characteristics. Additionally, enforced Dkk3 expression was examined in proliferation and tumorigenesis in vitro and in vivo, using MTT, soft agar assay, invasion assay, a xenograft mouse model, and a β-catenin-responsive SuperTopFlash luciferase assay.

Results

Compared with matched normal endometrial cases, Dkk3 was down-regulated in EC (p < 0.0001). Among cancer cases, Dkk3 expression was significantly reduced in patients with higher stage (p = 0.002), positive pelvic lymph nodes (p = 0.0004), non-endometrioid histology (p = 0.02), and cytology-positive ECs (p = 0.02). Enforced expression of Dkk3 in EC cell lines showed reduced proliferation (p < 0.0001), anchorage-independent growth (p = 0.005), invasion (p = 0.02), and reduced TCF activity (p = 0.04), confirming Dkk3 as a negative regulator of the β-catenin/Wnt signaling pathway. Tumor growth in Dkk3-injected mice was not statistically different, though did plateau towards the end, and was associated with increased lymphoid infiltration and tumor necrosis.

Conclusion

Dkk3 gene expression is frequently downregulated in endometrial cancer, and is associated with poor prognostic clinicopathologic markers. The results also identify a role for Dkk3 as a tumor suppressor in EC, affecting both proliferation and invasiveness. These findings may prove to be important in the design of novel biomarkers and treatment modalities for advanced EC.     

Knowledge, practices, and attitudes regarding emergency contraception among students at a university in Ghana

Objectives

To investigate the knowledge, practices, and attitudes among students at a university in Ghana regarding emergency contraception (EC).

Methods

An anonymous, self-administered, 39-item questionnaire was sent to 3200 students. The sample size was stratified and 2292 students were randomly selected.

Results

Of the 71.6% of students who responded, 51.4% had heard of EC. Among those, 19.4% thought EC consisted of contraceptive pills, 19.1% of “morning-after pills,” and 12.8% of an intrauterine device. Only 4.2% had ever used EC but 73.9% wished it were provided on campus. Of all the respondents, 90.9% called for the establishment of a reproductive health counseling center on campus.

Conclusion

Student knowledge and use of EC were poor, and there is urgent need for reproductive counseling and EC services on campus.     

Commercialisation and entrepreneurialism in maternity

Objective

against an international background, to examine the implications of private sector activity for maternity care in the United Kingdom National Health Service (UK NHS).

Background

the private sector and commercial or entrepreneurial activity in maternity services have attracted limited attention in the UK compared with, for e.g., Greece and the Irish Republic.

Method

discursive paper.

Key conclusions

despite rhetoric to the contrary, financial costs have always featured in the UK NHS. Financial payments in maternity have increased gradually. Commercial and entrepreneurial activity in maternity now includes ‘entertainment ultrasound’, reflecting a greater hegemonic imbalance. The commercialisation of maternity raises organisational, professional, quality-related and systematic issues, which all carry implications for the childbearing woman.

Relevance to clinical practice

the childbearing woman shoulders financial costs, whose origins and implications matter to both midwife and woman. The mixed benefits of medical investigations deserve closer attention.     

Report of the FIGO Working Group on Sexual Violence/HIV: Guidelines for the management of female survivors of sexual assault

Objective

To review the evidence and provide guidelines on the management of sexual violence against women, specifically, rape.

Outcomes

Outcomes evaluated include effectiveness of post-rape care provision.

Evidence

The MEDLINE database was searched for articles published up to December 2008 on the topic of post-rape care and expert opinion was sought from the Sexual Violence Research Initiative membership. In addition, a search was performed for English-language protocols on Google. One Spanish language protocol was considered in the development of the guidelines.

Values

The evidence was evaluated by authors and reviewers of the South African Department of Health’s sexual assault curriculum, and by members of the FIGO Working Group and recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Benefits, Harms, and Costs

Implementation of the recommendations in this Guideline should result in more appropriate management of survivors of sexual violence and better physical and psychological outcomes.