Dawn M. Kopp

Patterns of contraceptive adoption, continuation, and switching after delivery among Malawian women

Women who report use of postpartum family planning may not continue their initial method or use it consistently. Understanding the patterns of method uptake, discontinuation, and switching among women after delivery is important to promote uptake and continuation of effective methods of contraception. This is a secondary analysis of 634 Malawian women enrolled into a prospective cohort study after delivery. They completed baseline surveys upon enrollment and follow-up telephone surveys 3, 6, and 12 months post-delivery. Women were included in this analysis if they had completed at least the 3- and 6-month post-delivery surveys. Descriptive statistics were used to assess contraceptive method mix and patterns of switching, whereas Pearson’s χ2 tests were used for bivariable analyses to compare characteristics of women who continued and discontinued their initial post-delivery contraceptive method. Among the 479 women included in this analysis, the use of abstinence/traditional methods decreased and the use of long-acting and permanent methods (LAPM) increased over time. Almost half (47%) discontinued the contraceptive method reported at 3-months post-delivery; women using injectables or LAPM at 3-months post-delivery were significantly more likely to continue their method than those using non-modern methods (p<0.001). Of the 216 women who switched methods, 82% switched to a more or equally effective method. The change in contraceptive method mix and high rate of contraceptive switching in the first 12 months postpartum highlights a need to assist women in accessing effective contraceptives soon after delivery.

Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

Determine whether a 1‐hour pad test at discharge can identify continence status within 120 days of obstetric vesicovaginal fistula (VVF) repair.

Identifying Patients With Vesicovaginal Fistula at High Risk of Urinary Incontinence After Surgery.

OBJECTIVE: To develop a risk score to identify women with vesicovaginal fistula at high risk of residual urinary incontinence after surgical repair. METHODS: We conducted a prospective cohort study among 401 women undergoing their first vesicovaginal fistula repair at a referral fistula repair center in Lilongwe, Malawi, between September 2011 and December 2014, who returned for follow-up within 120 days of surgery. We used logistic regression to develop a risk score to identify women with a high likelihood of residual urinary incontinence, defined as incontinence grade 2–5 within 120 days of vesicovaginal fistula repair, based on preoperative clinical and demographic characteristics (age, number of years with fistula, human immunodeficiency virus status, body mass index, previous repair surgery at an outside facility, revised Goh classification, Goh vesicovaginal fistula size, circumferential fistula, vaginal scaring, bladder size, and urethral length). The sensitivity, specificity, and positive and negative predictive values of the risk score at each cut point were assessed. RESULTS: Overall, 11 (3%) women had unsuccessful fistula closure. Of those with successful fistula closure (n=372), 85 (23%) experienced residual incontinence. A risk score cut point of 20 had sensitivity of 82% (95% confidence interval [CI] 72–89%) and specificity 63% (95% CI 57–69%) to potentially identify women with residual incontinence. In our population, the positive predictive value for a risk score cut point of 20 or higher was 43% (95% CI 36–51%) and the negative predictive value was 91% (95% CI 86–94%). Forty-eight percent of our study population had a risk score 20 or greater and, therefore, would have been identified for further intervention. CONCLUSION: A risk score of 20 or higher was associated with an increased likelihood of residual incontinence with satisfactory sensitivity and specificity. If validated in alternative settings, the risk score could be used to refer women with a high likelihood of postoperative incontinence to more experienced surgeons.

Consequences of centralised blood bank policies in sub-Saharan Africa

Safe and reliable transfusion services remain largely unavailable to the world’s poorest populations, particularly in sub-Saharan Africa. WHO responded to this crisis with a strategy focused on centralising blood transfusion services, the exclusive use of volunteer donors, donor blood testing, and transfusion stewardship. On the basis of our experience in Malawi, we think that this policy has unintentionally decreased the availability of blood products for patients with acute haemorrhage. In response to this policy, the Malawi Blood Transfusion Service (MBTS) was established in 2003, replacing an inhospital model with a government-sponsored centralised service. By 2008, over two-thirds of the country’s blood donation was centralised and donation became increasingly dependent on unpaid volunteers rather than family member replacement. However, in 2014, data from MBTS showed that blood donation per-capita had decreased compared with 2011, meeting only onethird of blood products requested, largely because of a reliance on secondary and college students who donated 80% of MBTS blood. Prospective data from our study of 293 patients with upper gastrointestinal bleeding in Malawi corroborates that supply has decreased over time, showing that the number of units transfused per patient, adjusted for haemoglobin concentrations, decreased by nearly 50% between 2011 and 2013 (fi gure). The fundamental weakness in the WHO blood banking policy is the categorisation of blood donors and emphasis on strict centralisation. WHO recognises three types of donor: volunteer donors, replacement donors (family or friends), and compensated donors. In 2004, over 80% of blood donations in sub-Saharan Africa were from replacement donors, but that number is now closer to 40%. The policy emphasis on volunteer donors focuses on improving safety from infectious diseases, particularly HIV. Collaboration between WHO and the US President’s Emergency Plan for AIDS Relief has been instrumental in this strategy by setting transfusion policy priorities that focus on HIV transmission prevention or through direct funding for national transfusion services. These policies assume that volunteer donors have a lower risk profi le than compensated or replacement donors for key infectious diseases, although available evidence does not support this assumption. Several studies from sub-Saharan Africa have failed to show a safety benefi t with respect to HIV transmission when comparing replacement donors and volunteer donors. Instead, evidence shows that it is repeat donation from volunteer donors that improves safety. Centralised blood banking systems also have considerable fi nancial implications. Bates and colleagues estimated that a centralised, volunteer-based system in sub-Saharan Africa is 4–8 times more expensive per unit of blood than a hospital-based system. Additional costs accumulate from expansive quality assurance programmes, blood distribution to medical centres, and donor recruitment. Furthermore, the blood donor recruitment strategy developed in most centralised blood-banking systems is dependent on local schools and universities as the primary donor source population, a strategy that is only viable when educational institutions are in session. This problem has been documented in other African countries such as Burkina Faso. With centralisation, timely and effi cient distribution networks are key. However, mature blood distribution

Contraceptive uptake after training community health workers in couples counseling: A cluster randomized trial

Background Young women in Malawi face many challenges in accessing family planning (FP), including distance to the health facility and partner disapproval. Our primary objective was to assess if training HSAs in couples counseling would increase modern FP uptake among young women. Methods In this cluster randomized controlled trial, 30 HSAs from Lilongwe, Malawi received training in FP. The HSAs were then randomized 1:1 to receive or not receive additional training in couples counseling. All HSAs were asked to provide FP counseling to women in their communities and record their contraceptive uptake over 6 months. Sexually-active women <30 years of age who had never used a modern FP method were included in this analysis. Generalized estimating equations with an exchangeable correlation matrix to account for clustering by HSA were used to estimate risk differences (RDs) and 95% confidence intervals (CIs). Results 430 (53%) young women were counseled by the 15 HSAs who received couples counseling training, and 378 (47%) were counseled by the 15 HSAs who did not. 115 (26%) from the couples counseling group had male partners present during their first visit, compared to only 6 (2%) from the other group (RD: 0.21, 95% CI: 0.09 to 0.33, p<0.01). Nearly all (99.5%) initiated a modern FP method, with no difference between groups (p = 0.09). Women in the couples counseling group were 8% more likely to receive male condoms (RD: 0.08, 95% CI: -7% to 23%, p = 0.28) and 8% more likely to receive dual methods (RD: 0.08, 95% CI: -0.065, 0.232, p = 0.274). Conclusion Training HSAs in FP led to high modern FP uptake among young women who had never used FP. Couples counseling training increased male involvement with a trend towards higher male condom uptake.

Dual Method Use among Postpartum HIV-Infected and HIV-Uninfected Malawian Women: A Prospective Cohort Study

Dual method use, use of condoms plus another effective contraceptive method, is important in settings with high rates of unintended pregnancy and HIV infection. We evaluated the association of HIV status with dual method use in a cohort of postpartum women. Women completed baseline surveys in the postpartum ward and telephone surveys about contraceptive use 3, 6, and 12 months later. Nonpregnant women who completed at least one follow-up survey were eligible for this secondary analysis. Prevalence ratios were calculated using generalized estimating equations. Of the 511 sexually active women who completed a follow-up survey, condom use increased from 17.6% to 27.7% and nonbarrier contraceptive use increased from 73.8% to 87.6% from 3 to 12 months after delivery. Dual method use increased from 1.0% to 18.9% at 3 to 12 months after delivery. Dual method use was negligible and comparable between HIV-infected and HIV-uninfected women at 3 months but significantly higher among HIV-infected women at 6 months (APR = 3.9, 95% CI 2.2, 7.1) and 12 months (APR = 2.7, 95% CI 1.7, 4.3). Dual method use was low but largely driven by condom use among HIV-infected women at 6 and 12 months after delivery.

Contraceptive knowledge, use and intentions of Malawian women undergoing obstetric fistula repair

Abstract Objectives: Unintended pregnancy contributes to morbidities, such as obstetric fistula. Furthermore, after fistula repair, women should avoid pregnancy for a year to prevent its breakdown. Our study objective was to evaluate the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair at a centre in Malawi. Methods: This cross-sectional study used a standardised survey to examine the contraceptive knowledge, practices and intentions of women undergoing obstetric fistula repair in Lilongwe, Malawi, between September 2011 and November 2014. Log binomial models were used to examine correlates of prior and planned contraceptive use. Results: The analysis included 569 women, of whom 61.3% had heard of, and 38.7% had used a modern method of contraception. Women aged 20–49 years, married, with secondary education or higher and with living children were significantly more likely to report prior use of a modern contraceptive method. Of the 354 women who still had reproductive potential (premenopausal women who had not undergone sterilisation) and answered questions on future contraceptive use, less than half (41.6%) planned to use a modern method of contraception after fistula repair. Planned modern contraceptive use was significantly associated with being currently married and having secondary education or higher. Conclusions: Contraceptive knowledge, prior use and planned future use were low in our study population. To increase contraceptive use among women undergoing obstetric fistula repair, interventions in the postoperative period must seek to increase their family planning knowledge and access to contraceptive methods.

Authors’ reply re: Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

by patient self-reporting, which has a high risk of bias. It seems inconsistent to record objective data on pad weight prior to discharge but follow patients up using subjective methods. As the authors acknowledge, urodynamic testing would provide evidence of the severity and nature of residual incontinence. If subjective scoring is to be undertaken, acceptability of residual incontinence and quality of life measures would seem more relevant than the continence grading system used. Overall, this paper certainly highlighted the challenges faced by clinicians trying to improve long-term post-operative outcomes in this unique population of patients, and will hopefully act as a foundation for further research in the area.&

Association between parity and fistula location in women with obstetric fistula: a multivariate regression analysis

To compare primiparous and multiparous women who develop obstetric fistula (OF) and to assess predictors of fistula location.