Carolyn B. Sufrin

Neisseria gonorrhea and Chlamydia trachomatis Screening at Intrauterine Device Insertion and Pelvic Inflammatory Disease

OBJECTIVE: To evaluate the relationship between Neisseria gonorrhea and Chlamydia trachomatis screening strategies and risk of pelvic inflammatory disease (PID) after intrauterine device (IUD) insertion. METHODS: We conducted a retrospective cohort study of all IUD insertions at Kaiser Permanente Northern California from January 2005 to August 2009. The PID incidence within 90 days after insertion was compared among women who were and were not screened for N gonorrhea and C trachomatis. The study was powered for equivalence with a PID risk difference of −0.006 to 0.006 between two groups considered to be clinically insignificant. Risk difference was calculated by subtracting the proportion of females with PID in one screening group from the proportion of females with PID in the comparison screening group. RESULTS: Of 57,728 IUD insertions, 47% were unscreened within 1 year of insertion; of screened women, 19% were screened on the same day. The overall risk of PID was 0.54% (95% confidence interval [CI] 0.48–0.60%). Nonscreening had an equivalent risk of PID as any screening (risk difference −0.0034, 95% CI −0.0045 to −0.0022), and same-day screening was equivalent to prescreening (risk difference −0.0031, 95% CI −0.0049 to −0.0008). The equivalence persisted when adjusted for age and race and when stratified by age younger than 26 years and older than 26 years. CONCLUSION: The risk of PID in women receiving IUDs was low. These results support IUD insertion protocols in which clinicians test women for N gonorrhea and C trachomatis based on risk factors and perform the test on the day of insertion. These findings have potential to reduce barriers to IUD use for women seeking highly effective, long-term, reversible contraception. LEVEL OF EVIDENCE: II

Pharmaceutical industry marketing: understanding its impact on women's health.

The delivery of modern health care entails significant involvement from the pharmaceutical industry, including developing and manufacturing drugs. However, the industry also has tremendous influence on the practice of medicine through its considerable marketing efforts, both to patients through direct to consumer advertising, and to physicians through detailing, providing samples, continuing medical education, and other efforts. This article will review the role that pharmaceutical marketing plays in health care, and the substantial evidence surrounding its influence on patient and physician behaviors, with additional discussion of the medical device industry, all with particular attention to women’s health. Understanding the effects of pharmaceutical marketing on women’s health, through discussion of relevant examples—including oral contraceptive pills, drugs for premenstrual dysphoric disorder, Pap smear cytology techniques, and neonatal herpes prophylaxis—will help ensure that women receive unbiased, evidenced-based care. We will conclude with a discussion of guidelines that have been proposed by professional organizations, policy makers, and universities, to assist physicians in managing exposure to pharmaceutical marketing. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to identify ways that pharmaceutical marketing can impact clinical care, modify their own personal involvement with pharmaceutical marketing if necessary to avoid conflicts of interest, and illustrate particular vulnerabilities in women’s health with respect to pharmaceutical marketing.

Contraception services for incarcerated women: a national survey of correctional health providers

BACKGROUND Incarcerated women have had limited access to health care prior to their arrest. Although their incarceration presents an opportunity to provide them with health care, their reproductive health needs have been overlooked. STUDY DESIGN We performed a cross-sectional study of a nationally representative sample of 950 correctional health providers who are members of the Academy of Correctional Health Providers. RESULTS A total of 405 surveys (43%) were returned, and 286 (30%) were eligible for analysis. Most ineligible surveys were from clinicians at male-only facilities. Of eligible respondents, 70% reported some degree of contraception counseling for women at their facilities. Only 11% provided routine counseling prior to release. Seventy percent said that their institution had no formal policy on contraception. Thirty-eight percent of clinicians provided birth control methods at their facilities. Although the most frequently counseled and prescribed method was oral contraceptive pills, only 50% of providers rated their oral contraceptive counseling ability as good or very good. Contraception counseling was associated with working at a juvenile facility, and with screening for sexually transmitted infections. CONCLUSIONS Contraception does not appear to be integrated into the routine delivery of clinical services to incarcerated women. Because the correctional health care system can provide important clinical and public health interventions to traditionally marginalized populations, services for incarcerated women should include access to contraception.

Contraceptive use and barriers to access among newly arrested women

Incarcerated women report high rates of prior unintended pregnancies as well as low contraceptive use. Because jail could be a site of contraception care, this study aimed to assess women’s access to contraception prior to their arrest. A cross-sectional survey was administered to 228 reproductive-aged, nonpregnant women arrested in San Francisco. Twenty-one percent were currently using contraception. More than half (61%) had not used contraception in the last year, yet 11% wanted to have used it. Women in this latter subset reported greater difficulty with payment, finding a clinic, and transportation compared to women who had used contraception. In addition, 60% of all women in the sample would accept contraception if offered to them in jail. Thus, jail is a potentially important and acceptable point of access to contraception, which can circumvent some preincarceration logistical barriers.

County Jail as a Novel Site for Obstetrics and Gynecology Resident Education

INTRODUCTION Obstetrics and gynecology residents benefit from providing care to diverse patient populations and increasing their awareness of the social determinants of health. OBJECTIVES To describe and evaluate an outpatient rotation for obstetrics and gynecology residents at a county jail. METHODS A comprehensive curriculum incorporating Accreditation Council for Graduate Medical Education (ACGME) core competencies was designed for all first-year residents to rotate weekly at the local county jail during their 6-week ambulatory care block. Residents completed an anonymous online evaluation and wrote a reflective essay at the end of the rotation. Data for patient visits were tabulated. RESULTS All 9 first-year residents completed the rotation and the evaluation. Seventy-eight percent of patient visits were for gynecologic services, predominantly family planning. Residents reported that the rotation overall was a positive experience, emphasizing the unique intersection between psychosocial issues and health care in the jail setting. Rotation objectives that satisfied the 6 ACGME competencies were met. DISCUSSION Providing care to incarcerated women through a structured curriculum is a novel way to encourage obstetrics and gynecology residents to consider the social determinants of health and for residents to cultivate their counseling skills. The rotation also included a wide breadth and depth of clinical diagnoses and procedures. Obstetrics and gynecology residency programs should consider a curriculum in reproductive health for incarcerated women.

The "exhibit mall" at the American College of Obstetricians and Gynecologists annual clinical meeting: reflections on consumerism and medicine.

N Orleans is a city known for revelry and excess. Especially in the wake of Katrina, many residents pride themselves on maintaining this jubilant spirit, one which is often coupled with conspicuous consumption. This tone seemed appropriate as I meandered through the Exhibit Hall at this year’s Annual Clinical Meeting of the American College of Obstetricians and Gynecologists (ACOG). The air conditioning in the Convention Center was a welcome relief from the Louisiana humidity, as I disembarked from the CooperSurgical-sponsored shuttle bus. While the cool temperature lured me in, I had the opportunity to check my e-mail on computers with a high-speed internet connection. Thank you, Boehringer Ingelheim Pharmaceuticals and Eli Lilly, for the computer terminals. Upon registering for the conference, I was given a Merck lanyard for my name tag, and an Ortho Women’s Health and Urology tote bag with a stack of flyers, maps, and a 92-page “Exhibit Guide.” The logical next step seemed to enter the grand Exhibit Hall. Although I was immediately greeted warmly by a sales representative from Wyeth Pharmac-