Ayşen Bulut

Assessing the acceptability, service delivery requirements, and use-effectiveness of the diaphragm in Colombia, Philippines, and Turkey.

The diaphragm is not available in many countries, despite the recommendations of numerous authors that it has important advantages as a woman-controlled method that offers some protection against sexually transmitted diseases, and one that is safe and free of side effects. An interagency team collaborated to introduce the diaphragm in Colombia, the Philippines, and Turkey, using the same protocol to assess the acceptability, service delivery requirements and use-effectiveness of the method. Eighteen public and private sector service delivery sites were involved and a total of 550 women were enrolled in the study. Provider training aimed to improve the quality of care with which all methods were delivered and included counseling about sexuality and reproductive health risks. The cumulative 12-month pregnancy rate of 10.1 (SE 1.7) per 100 woman-years is on the low end of previous studies of the diaphragm, and the 12-month continuation rate (57.2 [SE 2.4] per 100) compares favorably with that for oral contraceptives and the intrauterine device. Focus group discussions conducted with clients and providers indicated that the method was an important alternative for some women, particularly those who had experienced health problems with other methods or were unable to negotiate condom use with their partners. Provider biases diminished as they observed the strategic niche that the diaphragm filled for their clients. While providing the diaphragm requires training and good client-provider interaction, the requirements are consistent with those called for in the Programme of Action of the International Conference on Population and Development (ICPD, 1994). With proper attention to quality of care, the diaphragm can be successfully offered in resource-poor settings.

Asking questions about women's reproductive health: validity and reliability of survey findings from Istanbul

In countries where population‐based data on health problems are scarce, the extent of reproductive morbidity can be estimated from replies in structured interviews as a complement or as an alternative to reports from physicians examination and laboratory tests. We examined the sensitivity and specificity of detected morbidity based on these replies as compared to medical diagnoses and explored the consistency of replies when the questionnaire was administered twice, by two types of interviewers in different environments. Data were collected in a cross‐sectional survey in Istanbul. The presence or absence of five morbidities, reproductive and urinary tract infections (RTI and UTI), menstrual disorders, pelvic relaxation and anaemia was determined by algorithms based on the replies, and by the physicians diagnosis. Except with anaemia, questionnaire replies were more specific than sensitive in detecting morbidity, probably partly due to many morbid conditions being accepted as normal. Specificity exceeded 80% for home reports of menstrual disorders (93.0%), pelvic relaxation (95.7%), RTI (abnormal discharge and pain) (81.2%) and UTI (80.7%), with the corresponding figure for anaemia at 41.7%; the best sensitivity results were for anaemia (58.3%), RTI (abnormal discharge only) (49.3%) and menstrual disorders (45.4%) with figures for pelvic relaxation and UTI reaching only 17.3 and 13.0%. Reliability between the interviews (assessed by the κ coefficient), was highest at 66.1% for pelvic relaxation and lowest at 39.9% for menstrual disorders. Reliability varied between the two lay interviewers, suggesting the interviewer and the interview conditions are important. Questionnaire‐based information on this type of morbidity is most useful for ascertaining perceived ill‐health and only of limited use for the corresponding medically defined conditions.

Contraceptive choice and reproductive morbidity in Istanbul.

A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of bearing a considerable burden of ill health, with 81 percent reporting at least one episode of illness in the three months prior to the interview. Current users of the intrauterine device were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small amount of switching between methods suggests that most users tended to stay with the same method once chosen and that health concerns played an important part only in the initial choice of the method.

Immediate postabortal contraception with the levonorgestrel intrauterine device, Norplant, and traditional methods.

Women seeking legal first trimester abortion were counseled concerning contraception methods available for use immediately postabortion. Fifty women each accepted hormonal methods that were available only in the clinic and were novel to the country, the levonorgestrel IUD and Norplant implants, whereas another 50 chose either coitus interruptus or abstinence. All were experienced contraceptors, but larger percentages of women selecting the levonorgestrel IUD or implants had used the pill or IUDs previously, were under age 30, and weighed less than 60 kg compared to the other study participants. In the initial 2-6 weeks postabortion, women using the long-acting hormonal methods resumed sexual activity earlier and experienced more bleeding and spotting days than did other study participants, but their hematocrits were not adversely affected. No clinically significant side effects were noted in any group in the 6 weeks following the abortion. At the end of 1 year of follow-up, women using the hormonal methods had experienced no pregnancies and had high rates of continuation. IUD and implant participants had greater weight gain than did the other participants, but their mean weight remained below that of participants using traditional methods. No significant between-group differences in levels or changes in levels from admission were noted in hematocrit and blood pressure. The women found the levonorgestrel implants and IUDs easy and safe to use and highly effective. Bleeding disturbances, including amenorrhea, were the principal features the women disliked.

In search of truth: Comparing alternative sources of information on reproductive tract infection

Abstract This study, carried out in Istanbul, compared the reliability of self-reporting, clinical diagnosis and laboratory examinations for determining the extent of reproductive tract infections in 696 women. It found that a physician diagnosed an infection in more than half the women who did not report a problem spontaneously, and in only two-thirds of those who did report a problem. According to the laboratory examination, less than a fifth of those reporting a problem had an infection, while 76 per cent of those who did not recognise they had a problem in fact had one. Worse still, of the women that the physician diagnosed as not having an infection, 69 per cent actually had one. This study shows that using the ‘syndromic’ approach alone has a poor predictive value, that laboratory testing for reproductive tract infections is also essential and that inexpensive tests need to be developed. In addition, the establishment of a standardised symptoms checklist to use in interviews with women and standardised diagnostic criteria for RTIs that include both physicians diagnosis and laboratory test results deserves immediate attention.

Is the diaphragm a viable option for women in Turkey

Diaphragms were offered to women as a contraceptive option during counseling sessions at four family planning clinic sites in western Turkey: two public-sector clinics (one in Capa Istanbul; the other in Izmir) and two private-sector clinics (one in Incirli Istanbul; the other in Denizli). Women who chose the diaphragm were interviewed at enrollment and were invited for follow-up visits with a physician at 2 weeks and at any time thereafter. Demographic information was also collected from an additional 740 women who chose another contraceptive method and focus-group discussions were conducted with diaphragm users and their partners with users of other methods and with service providers. Overall 166 women selected the diaphragm and 161 enrolled in the study. Initial acceptance rates were higher at the two private clinics (14% and 6%) than at the two public clinics (3% and 1%). At the public-sector clinics diaphragm users were better educated and more likely to be professionally employed than were women who selected other contraceptive methods. In Capa 42% of women who chose the diaphragm were university graduates compared with 7% of those who chose another method. Despite differences between the two private clinics in clients educational levels no such differences existed between diaphragm acceptors and users of alternative methods at each site. Among women who chose the diaphragm 47% said they had sex four times or more per week compared with 29% of those using another contraceptive. More than half of the women who selected the diaphragm (59%) cited safety and freedom from side effects as the reason for their choice of contraceptive. A similar percentage of clients who used other methods (58%) cited effectiveness. 50% of diaphragm users had discontinued by 6 months and 66% had done so by 12 months. A small proportion of clients in both private- and public-sector clinics were interested in using the diaphragm and found it acceptable. In less-developed countries the diaphragm may be a viable contraceptive option when providers are able to provide adequate information and support. (authors)

Postpartum Family Planning and Health Needs of Women of Low Income in Istanbul

This study was designed to learn what types of postpartum health and family planning services are most appropriate for couples with low incomes living in Istanbul, Turkey. The methods used included focus groups, site visits, questionnaires for postpartum women, and a self-administered questionnaire for health-care providers. By five months postpartum, 86 percent of the women surveyed were using some method of family planning. Many couples used withdrawal, starting immediately upon resumption of intercourse after childbirth, intending to use a medical method after menses resumed. However, only 34 percent of users had begun to use a medical method by five months after childbirth. The health facilities visited provide little information and counseling about the postpartum period. Women said that they wanted information on infant care, breast-feeding, and family planning, either before becoming pregnant or while they are pregnant. Most women prefer that postpartum services address the needs of the whole family, not only those of the baby or the mother. Recommendations for the timing, mode, and content of postpartum health and family planning services are made based on the studys findings.

The effectiveness of preabortion contraception counseling

Objective: To demonstrate the impact of preabortion counseling followed by immediate postabortal provision of the chosen method on postabortion contraceptive use. Methods: Three hundred and forty‐two women undergoing voluntary termination of pregnancy at less than 10 weeks gestation were enrolled at the Woman and Child Health Training and Research Clinic, Medical School of Istanbul. Clinic visits and telephone surveys were performed to measure contraceptive use at 6 months following abortion. Result: Two hundred and thirty‐six women either visited the clinic or responded to the telephone survey. Eighty percent of the respondents reported use of a modern contraceptive as compared to less than 40% prevalence found in the national survey. Conclusion: Preabortion counseling combined with immediate postabortal provision of contraceptives may significantly increase contraceptive use at 6 months postprocedure.

The effects of vaccination with inactivated uropathogenic bacteria in recurrent urinary tract infections of children.

Secretory IgA (sIgA) is an important parameter in the predisposition to recurrent urinary tract infection (UTI). We investigated whether sIgA and frequency of UTI could be positively influenced by intramuscular vaccination with inactivated uropathogenic bacteria (Solco-Urovac). Ten otherwise healthy girls aged from 5 to 11 years (mean 9 1.7 years) with recurrent UTI were immunized with Solco-Urovac by i.m. injections three times at weekly intervals. A booster injection was given after 6 months. Urinary sIgA secretory component (SC) concentration was determined by radial immunodiffusion assay. Ten other age-matched girls with UTI were not immunized. Immunization therapy caused a significant reduction in the frequency of infection and an increase in urinary sIgA SC, while in the nonvaccinated group the values remained constant.

Paraprofessional women as health care facilitators in mother and child health.

The aim of the study was to compare the performance of midwives with that of lady home visitors (LHV; paraprofessionals). The project area was divided into six according to the population map. One midwife or one LHV was assigned to each visiting area. Home visits were carried out to identify and offer guidance on family planning (FP), antenatal care, well-child control, immunizations and other mother and child health related issues to those at high risk. Criteria taken for evaluation were the numbers of pregnant women identified in the last trimester; pregnant women receiving antenatal care; deliveries attended by a health care provider; modern FP users; continuation rate of the new users; pregnancy rate in new users; immunization status of children; well-child visits of the children. No significant differences were found in these health measurements between areas visited by LHV and areas visited by midwives. Response rates to the invitation was also similar in both areas. An important observation was the good performance of the LHV in communicating with the families. Women with limited school attainment from the community can be used effectively and efficiently in community health services.