Elizabeth Oliveras

Health system costs of menstrual regulation and care for abortion complications in Bangladesh.

CONTEXT Treatment of complications of unsafe abortion can be a significant financial drain on health system resources, particularly in developing countries. In Bangladesh, menstrual regulation is provided by the government as a backup to contraception. The comparison of economic costs of providing menstrual regulation care with those of providing treatment of abortion complications has implications for policy in Bangladesh and internationally. METHODS Data on incremental costs of providing menstrual regulation and care for abortion complications were collected through surveys of providers at 21 public-sector facilities in Bangladesh. These data were entered into an abortion-oriented costing spreadsheet to estimate the health system costs of providing such services. RESULTS The incremental costs per case of providing menstrual regulation care in 2008 were 8-13% of those associated with treating severe abortion complications, depending on the level of care. An estimated 263,688 menstrual regulation procedures were provided at public-sector facilities in 2008, with incremental costs estimated at US

20 years of HIV in Bangladesh : experiences and way forward

2.2 million, and 70,098 women were treated for abortion-related complications in such facilities, with incremental costs estimated at US

Quality of life of Ethiopian women after fistula repair: implications on rehabilitation and social reintegration policy and programming

1.6 million. CONCLUSION The provision of menstrual regulation averts unsafe abortion and associated maternal morbidity and mortality, and on a per case basis, saves scarce health system resources. Increasing access to menstrual regulation would enable more women to obtain much-needed care and health system resources to be utilized more efficiently.

Addressing unmet need for long-acting family planning in Ethiopia: Uptake of single-rod progestogen contraceptive implants (Implanon) and characteristics of users

This report synthesizes data from surveillance, behavioral surveys and published and unpublished research to better understand emerging patterns and trends in the HIV epidemic in Bangladesh. Taking stock of 20 years of experience with HIV in Bangladesh, this report summarizes what is known about the coverage and impact of HIV prevention services, including knowledge on risk and protective behaviors. The report is divided into nine chapters. Chapter one provides a brief introduction and an overview of the methodology used for this exercise. Chapter two discusses the risks and vulnerabilities of the high risk groups including female sex workers, injecting drug users, male who have sex with male, hijra and overlapping populations, while chapter three discusses the trend of the infection amongst partners of high risk groups. Bangladesh continues to report low condom use, which is analyzed and discussed in chapter four. Structural factors including macro level and intermediate level factors that affect HIV interventions in Bangladesh are addressed in chapter five. The national HIV response is discussed in chapter six. The report concludes with a discussion of the main findings, with recommendations for the future in chapter seven, and chapter eight and nine are annexes and references.

Effect of post-menstrual regulation family-planning service quality on subsequent contraceptive use in Bangladesh.

Despite growing recognition of the importance of linking obstetric fistula prevention and treatment strategies with rehabilitation and social reintegration programmes, little research and programming has been oriented toward this goal. Using in-depth interviews, this study aimed to examine the experiences of 51 Ethiopian women after fistula repair surgery to identify priority post-repair interventions that could maximise their quality of life. The results showed that the majority of women felt a dramatic sensation of relief and happiness following repair, yet some continued to experience mental anguish, stigma, and physical problems regardless of the outcome of the procedure. All women suffered intense fear of developing another fistula, most commonly from sex or childbirth. Despite this, the majority of women had sex or planned to do so, while a smaller cohort avoided intercourse and childbearing, thus subjecting them to isolation, marital conflict, and/or economic vulnerability. Our findings suggest that obstetric fistula programmes should integrate (1) post-repair counselling about fistula and risk factors for recurrence, (2) community-based follow-up care, (3) linkages to income-generating opportunities, (4) engagement of women affected by fistula for community outreach, and (5) metrics for evaluating rehabilitation and social reintegration efforts to ensure women regain healthy, productive lives.

Quality and efficiency of care for complications of unsafe abortion: a case study from Bangladesh.

To describe women who accept single‐rod progestogen contraceptive implants (Implanon; N.V. Organon, Oss, Netherlands) from community health workers in Ethiopia and to assess whether community‐based provision addresses unmet need for contraception.

Improving STI counselling services of non-formal providers in Bangladesh: testing an alternative strategy

To determine whether the quality of post‐menstrual regulation family‐planning services (post‐MRFP) affected contraceptive use at 3‐month follow‐up.

The Effect of Integrating Family Planning with HIV and Aids Services on Contraceptives Uptake among HIV Positive Women

Treating complications of unsafe abortion can be financially draining for health systems. This analysis assessed incremental health system costs of service delivery for abortion‐related complications in the Bangladesh public health system and confirmed that providing postabortion care with vacuum aspiration is less expensive than using dilation and curettage (D&C). Implementing several evidence‐based best practices, such as replacing D&C with vacuum aspiration, reducing use of high‐level sedation, authorizing midlevel providers to offer postabortion care, and providing postabortion contraceptive counseling and services to women while still at the health facility, could increase the quality and cost efficiency of postabortion care in Bangladesh.

Performance of female volunteer community health workers in Dhaka urban slums

Objective The authors conducted this study to assess the effectiveness of using a public health detailing approach by medical representatives of a private pharmaceutical company to disseminate sexually transmitted infection (STI) counselling information to non-formal providers (NFPs) to improve their STI counselling services. Methods An intervention was developed that included developing STI counselling guidelines and training medical representatives to disseminate the counselling guidelines to NFPs. To assess the effectiveness of this intervention, the authors conducted 67 mystery client visits to compare the counselling provided by NFPs in intervention areas with counselling provided in areas where the intervention was not implemented. Results A significantly higher proportion (p<0.05) of mystery clients in the intervention area received advice that was consistent with the national STI counselling guidelines compared with the mystery clients in the control area. No mystery clients in the control area were told to use condoms while the STI lasts compared with 44% (95% CI 28% to 62%) in the intervention area. Likewise, more than twice as many clients in the intervention area were advised not to visit sex workers (53% vs 23%; p=0.014). Conclusion Public health detailing of medical representatives is a feasible mechanism to improve STI counselling services of NFPs in Bangladesh. Private sector companies provide a potential avenue for reaching the vast number of NFPs with basic information that they can share with their clients. The immediate improvements seen in this study suggest the strong potential of public health detailing as a training tool for NFPs.

“I have grown up controlling myself a lot.” Fear and misconceptions about sex among adolescents vertically-infected with HIV in Tanzania

Background: Integrating Family Planning (FP) into HIV services provides opportunity to increase access to contraception among clients. However, data on the effectiveness of FP/HIV integration on FP uptake is limited. Objective: Determine the effect of FP/HIV services integration, focusing on FP integration with Antiretroviral Therapy (ART) Methods: A cross-sectional comparative design was conducted in facilities with and without FP/ART integration in four major regions of Ethiopia. The study population included HIV positive women attending ART clinics. Data were collected using structured questionnaire from 843 and 691 HIV positive women in intervention and comparison facilities respectively from April 23 to May 2, 2012. Data entry and analysis was done using SPSS version 17.0 and proportions and relevant associations were computed. Results: Most of the women (94.7%) received one or more HIV services. In both groups, 736 (48.2%) women used any type of FP method; the majority (97%) used modern FP and 54.6% used injectables. Over all CPR was 48%; with higher CPR in intervention than comparison group (52.6 %versus 42.9%) [AOR (95%CI) =1.23, (1.23, 1.92). A higher proportion of women in intervention than comparison group used dual methods [AOR (95%CI) =1.50 (1.01, 2.2)]. Total unmet need for FP in the study was 16.2 percent. There was no significant difference in unmet need for FP between intervention and comparison groups (15.7% vs. 16.9% respectively) [(OR 0.94 95% CI (0.63, 1.39)]. Conclusion and Recommendation: FP/HIV integration improved CPR and use of dual methods showing the benefit of FP/HIV integration. However, there was no difference in unmet need for FP between the two groups calling the need for more research.