A.L.M. Lagro-Janssen

Complications of the intrauterine device in nulliparous and parous women.

Objectives: The intrauterine device (IUD) is still related to pelvic inflammatory disease (PID), pregnancy, expulsion, perforation and menstrual problems, particularly in nulliparous women. We aimed to study the complications and symptoms of the intrauterine device in general practice, particularly in nulliparous women. Methods: We used a retrospective cohort study in four general practices participating in the Nijmegen Continuous Morbidity Registration. Selected women had one or more IUDs inserted between 1981 and 2000. Data on complications, symptoms and removal of the IUD were obtained from the medical records. Results: 461 women were included, 129 nulliparous and 332 parous women. Users of copper IUDs had a rate of PID of 3.5 per 1000 women-years, rates of (ectopic) pregnancy of 0.6 to 1.1% per year and rates of expulsion of 0 to 1.2% per year. Rates of expulsion for the levonorgestrel-releasing IUDs were 0 to 0.2% per year. Nulliparous women did not show more complications than parous women. Menstrual problems were frequent among users of copper and levonorgestrel-releasing IUDs. One third of the IUDs were removed within the first year after insertion. There was no significant excess of IUD removal among nulliparous women compared with parous women. Main reasons for removal were ‘menstrual problems’ and ‘contraception no longer necessary’. Conclusion: Both copper and levonorgestrel-releasing IUDs are safe and highly effective contraceptives, which can adequately be inserted and monitored by general practitioners in nulliparous and parous women.

Integrating gender into a basic medical curriculum

Introduction  In 1998, gaps were found to exist in the basic medical curriculum of the Radboud University Nijmegen Medical Centre regarding health‐related gender differences in terms of biological, psychological and social factors. After screening the curriculum for language, content and context, adjustments aimed at incorporating gender issues were proposed. The aim of this study was to evaluate those adjustments, as well as to investigate whether gender had been successfully incorporated into the basic medical curriculum, and to identify the factors that played a role in this.

Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology

Objectives  This study aimed to review the availability and accessibility of gender‐specific knowledge in current medical textbooks used in Dutch medical schools. Medicine has been criticised as being gender‐biased by assuming male and female bodies to be generally the same. The authors wondered whether current nationally and internationally accepted medical textbooks reflect the state of the art on gender‐specific knowledge.

Prevalence of intimate partner violence among migrant and native women attending general practice and the association between intimate partner violence and depression

OBJECTIVE To explore the prevalence of intimate partner violence (IPV) of women (aged >18 years) attending general practice and to assess the association between IPV and depression. METHODS A cross-sectional survey was conducted within 15 general practices across Rotterdam. The study population was all women older than 18 years of age attending general practice. Women were screened for sociodemographic factors, IPV and depression using the Composite Abuse Scale and the Beck Depression Inventory. RESULTS This study had a response rate of 63% (221 of 352 women). Two hundred and fourteen women were included in the study of whom 41% were migrants. Thirty per cent of the women attending general practise ever experienced IPV. Migrants experienced IPV 1.5 times more often compared to Dutch women. A significant association between IPV and depression was found. Half of the abused women were suffering from a depression. More than three-quarter of depressed women ever experienced IPV. CONCLUSIONS IPV is common in women attending general practice and it is significantly associated with depression. To improve recognition of abused women, doctors should ask depressed women if they ever experienced IPV.

Persisting rise in referrals during labor in primary midwife-led care in the Netherlands

BACKGROUND There are concerns about the Dutch maternity care system, characterized by a strict role division between primary and secondary care. The objective of this study was to describe trends in referrals and in perinatal outcomes among labors that started in primary midwife-led care. METHODS We performed a descriptive study of all 789,795 labors that started in primary midwife-led care during 2000 to 2008 in The Netherlands. Referrals to obstetrician-led care or pediatrician were classified as urgent or nonurgent. Perinatal safety was described by perinatal mortality (intrapartum or neonatal 0-7 days), admission to neonatal intensive care unit 0-7 days, and Apgar score < 7 at 5 minutes. RESULTS The proportion of referrals during labor or after birth declined from 52.6 to 42.6 percent for nulliparous women and from 83.2 to 76.7 percent for multiparous women. Especially nonurgent referrals during the first stage increased, for nulliparous women from 28.7 to 40.7 percent and for multiparous women from 10.5 to 16.5 percent. Referrals were less frequent in planned home births. Perinatal mortality was 0.9 per thousand births for nulliparous women, and 0.6 per thousand for multiparous women. A low Apgar score was registered in 8.6 per thousand births for nulliparous women, and 4.1 per thousand for multiparous women. CONCLUSIONS There was a considerable rise in nonurgent referrals to obstetrician-led care in primary midwife-led care during labor. Perinatal safety did not improve significantly over time. The persisting rise in referrals challenges the sustainability of the current strict role division between primary and secondary maternity care in The Netherlands.

Health care utilisation and problems in accessing health care of female undocumented immigrants in the Netherlands

ObjectiveTo obtain information about the actual use of health care facilities by undocumented women and to identify obstacles they experience in accessing health care facilities.MethodsA mixed methods study, with structured questionnaires and semi-structured interviews, was chosen to obtain a complete understanding. One-hundred undocumented women were recruited. Diversity was sought according to age, origin and reason for being undocumented.ResultsUndocumented female immigrants have unmet health care needs (56%) and low health care utilisation. Sixty-nine per cent of the women reported obstacles in accessing health care facilities. These included many personal obstacles such as shame, fear and/or lack of information. Poor language proficiency (OR 0.28;. CI 0.09–0.90) reduces utilisation of primary health care services.ConclusionHealth care utilisation of undocumented women is low. Undocumented women refrain from seeking health care because of personal obstacles. These women need to be identified and informed about their rights, the health care system and the duty of professional confidentiality of doctors. Finally, institutional obstacles to access care should be removed since they strengthen reluctance to seek help.

Help-seeking behaviour of Serbian women who experienced intimate partner violence

OBJECTIVE This study aimed to identify whom women in Serbia approach for help in case of intimate partner violence (IPV), their reasons for seeking help and their satisfaction with the received help. METHODS A cross-sectional, population-based household survey of a random sample of women aged 15-49 years was conducted in Belgrade (WHO Multi-country Study on Womens Health and Domestic Violence against Women). A standard questionnaire was administered by trained interviewers through face-to-face interviews. RESULTS The questionnaire was completed by 1456 women and 1196 of them ever had an intimate partner. Almost one in four ever-partnered women reported experiencing either physical and/or sexual violence, at least once in their life. Among these abused women, ≈ 22% had ever sought help from formal institutions. Police and health services were most commonly approached (12% and 10% of abused women, respectively). Satisfaction with services was highest for health services and legal advice and lowest for police and social services. Women sought help especially when violence had a severe impact on them or when they saw that their children suffered. Women who did not seek help stated that they believed that the violence was bearable or had ended. Other reasons for not seeking help were fear of undesirable consequences of seeking help and lack of trust in institutions. CONCLUSIONS From the abused womens perspective, health care services are the institutions with the highest potential to help women in cases of IPV. Developing a comprehensive health sector response is of critical importance to ensure appropriate care and referral.

Sexual harassment during clinical clerkships in Dutch medical schools

Context  Sexual harassment of medical students has been the focus of many international studies. Prevalence rates from 18% to over 60% have been reported. However, a Dutch study at Nijmegen Medical School found the prevalence rate to be lower (13.3% in the total group; 20% among female students only).

Birth setting, transfer and maternal sense of control: results from the DELIVER study

BackgroundIn the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the childbirth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital.MethodsWe used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant.ResultsNulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred.ConclusionWe found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.As far as their expected sense of control is concerned, low risk women should be encouraged to give birth at the location of their preference.

Significant fall in hormone replacement therapy prescription in general practice

BACKGROUND Hormone replacement therapy (HRT) in the past has been used in one of five women but not without significant short-term and long-term consequences. Objective. The aim of the study is to assess the prescription of HRT in general practice to women consulting with menopausal symptoms, before and after publication of the Womens Health Initiative (WHI) study (2002), the Million Women Study and the Lancet Editorial (2003), and to correlate these with co-morbidity, co-medication and frequency of GP consultation. Methods. The study was performed using data collected by a Dutch Continuous Morbidity Registration. We selected women who presented with menopausal symptoms for the first time during the period 1999-2007 (n=341). Women who were prescribed HRT between 2002 and 2007 were compared with women presenting with menopausal symptoms without HRT prescription and women who did not consult for menopausal symptoms. Both control groups were matched for age, socio-economic status and general practice. Results. HRT prescription decreased considerably: from 37% in all women who present with menopausal symptoms at the GP 2002 to 14% in 2003 and 4% in 2004. Women who consulted for menopausal symptoms, irrespective of HRT prescription, presented with nervous functional complaints more often, were prescribed more tranquillizers and visited the GP more frequently than women who did not consult for menopausal symptoms. Conclusions. These GPs were very quick to implement new recommendations on HRT prescription. The decision to prescribe HRT was not correlated with specific emotional or psychiatric problems of the menopausal women.