Heidi E. Jones

First trimester surgical abortion practices: a survey of National Abortion Federation members

BACKGROUNDnDesignated providers in specialized clinics perform the majority of approximately 1.1 million first-trimester abortions carried out in the United States each year. Our objective was to assess the first-trimester surgical abortion practices of National Abortion Federation (NAF) members.nnnSTUDY DESIGNnWe mailed questionnaires to NAF administrators and providers at their 364 active-member facilities in 2002.nnnRESULTSnTwo hundred eighty-nine (79%) facilities responded; we received administrative questionnaires from 273 facilities and 293 individual clinicians. NAF facilities provided at least 325,000 first-trimester surgical abortions in the United States in 2001. The majority of providers are obstetrician-gynecologists (63%), male (62%) and at least 50 years old (64%). Half of clinicians (49%) selectively utilize manual vacuum aspiration. Almost half (47%) routinely use a metal curette to verify procedure completion; these providers are more likely to be over 50 years of age or to have 20 years or more of abortion experience. Other practices are more uniform, including routine tissue examination (93%), postoperative antibiotics (88%) and contraceptive provision (oral contraceptives, 99%; depot medroxyprogesterone acetate, 79%).nnnCONCLUSIONSnMost perioperative practices for first-trimester abortions are similar among these respondents, in accord with evidence-based guidelines. The aging of skilled practitioners raises concerns about the future availability of surgical abortion.

Using Sexually Transmitted Infection Biomarkers to Validate Reporting of Sexual Behavior within a Randomized, Experimental Evaluation of Interviewing Methods

This paper examines the reporting of sexual and other risk behaviors within a randomized experiment using a computerized versus face-to-face interview mode. Biomarkers for sexually transmitted infection (STI) were used to validate self-reported behavior by interview mode. As part of a parent study evaluating home versus clinic screening and diagnosis for STIs, 818 women aged 18-40 years were recruited in 2004 at or near a primary care clinic in São Paulo, Brazil, and were randomized to a face-to-face interview or audio computer-assisted self-interviewing. Ninety-six percent of participants were tested for chlamydia, gonorrhea, and trichomoniasis. Reporting of STI risk behavior was consistently higher with the computerized mode of interview. Stronger associations between risk behaviors and STI were found with the computerized interview after controlling for sociodemographic factors. These results were obtained by using logistic regression approaches, as well as statistical methods that address potential residual confounding and covariate endogeneity. Furthermore, STI-positive participants were more likely than STI-negative participants to underreport risk behavior in the face-to-face interview. Results strongly suggest that computerized interviewing provides more accurate and reliable behavioral data. The analyses also confirm the benefits of using data on prevalent STIs for externally validating behavioral reporting.

Acceptability of Carraguard, a candidate microbicide and methyl cellulose placebo vaginal gels among HIV-positive women and men in Durban, South Africa

Background and MethodsWhen on the market, microbicides are likely to be used by individuals who do not know their HIV status. Hence, assessment of safety and acceptability among HIV positive men and women is important. Acceptability of Carraguard, the Population Councils lead microbicide candidate was assessed in a Phase I safety study among healthy HIV-positive sexually abstinent women and men, and sexually active women (20 per group), in Durban, South Africa. Participants were randomized to use Carraguard gel, placebo gel, or no product. All women in the gel arms applied 4 ml gel vaginally every evening for 14 intermenstrual days (women in the sexually active group inserted gel within 1 hour prior to sex on days when sex occurred), and sexually abstinent men applied gel directly to the penis every evening for 7 days. Acceptability was assessed by face-to-face structured questionnaires and semi-structured in-depth interviews with all participants. Gel use questions were applicable to participants in the gel arms only (13 sexually abstinent women, 14 sexually active women, and 13 abstinent men).ResultsOverall, 93% of the women liked the study gel (Carraguard or placebo) very much, 4% disliked it somewhat, and 4% were neutral. 15% of men and women disliked the gels color, smell, or packaging. Most women and men reported never experiencing pain or irritation during or after gel application. Although over two thirds of the women preferred some lubrication during sex, some of the women felt that the gel was frequently too wet. Twenty-one percent of women and 42% of men said they felt covert use of a microbicide would be acceptable. Over 60% of women and men would prefer to use a microbicide alone instead of using it with a condom.ConclusionAcceptability of Carraguard among HIV-positive women and men in Durban was good. The wetness experienced by the women may be attributed to the delivery of gel volume. The applicator was designed to deliver 4 mls whereas in fact between 4 ml to 5 mls were actually dispensed. Condom migration in the event of a partially effective product is of concern.

Effectiveness and safety of digoxin to induce fetal demise prior to second-trimester abortion

BACKGROUNDnThe study was conducted to assess the effectiveness in inducing fetal demise through digoxin injection given 1 day prior to second-trimester pregnancy termination and to evaluate related maternal safety.nnnSTUDY DESIGNnA retrospective cohort analysis of 1795 pregnant women between 17 and 24 weeks gestation who received varying doses of digoxin by transabdominal intrafetal or intra-amniotic injection at the time of laminaria placement was conducted. Fetal heart activity documented by M-mode Doppler sonography on the subsequent day was considered failure. Digoxin dosages started at 1.0 mg for intrafetal and 0.5 mg for intra-amniotic injections and were progressively decreased based on best clinical judgment.nnnRESULTSnThe overall rate of failure to achieve fetal demise was 6.6% (95% CI, 5.5-7.9). Failure rates varied according to route of administration and dosage. There were no failures using a 1.0-mg intrafetal dose, but failures occurred with lower doses. Failure rates were higher with 0.5 mg for intra-amniotic (8.3%) than intrafetal administration (3.6%). There were no adverse maternal events at any of the doses in this study.nnnCONCLUSIONnIntrafetal digoxin injection at a dose of 1.0 mg is safe and effective for fetal demise prior to pregnancy termination in the second trimester. Significantly lower doses are effective in most cases. Additional doses merit further testing.

Improving Quality of Care and Use of Contraceptives in Senegal

In the 1990s, the government of Senegal implemented a series of policy changes for the provision of family planning services through the public sector. A strategy to provide high quality services through reference centres was adopted. This paper presents findings from a longitudinal survey of 1,320 Senegalese women who had sought family planning services at ten public sector facilities--five reference centres and five health centres. Information was collected on the quality of care they received at the time they adopted family planning. One thousand one hundred and ten of the respondents were followed up sixteen months later to ascertain their contraceptive status. The first principal finding was that attendees at reference centres reported receiving relative better care than those who attended health centres. On average, clients at reference centres received 4.3 out of five units of care, compared to 3.8 units as reported by health centre clients. Second, multivariate analyses indicated that quality of care received at the time of adopting a contraceptive has a significant influence on subsequent contraceptive use. Those who received good care were 1.3 times more likely to be using a method than others.

Medical abortion practices: a survey of National Abortion Federation members in the United States

BACKGROUNDnLittle is known about clinical implementation of medical abortion in the United States following approval of mifepristone as an abortifacient by the Food and Drug Administration (FDA) in 2000. We collected information regarding medical abortion practices of National Abortion Federation (NAF) members for the year 2001.nnnMETHODSnQuestionnaires were mailed to 337 active US NAF member facilities.nnnRESULTSnA total of 258 facilities responded (77%); 252 nonhospital facilities were included in the analysis. Most of these facilities (87%) offered medical abortion in 2001, providing an estimated 28,400 medical abortions, approximately 52% of medical abortions in the US that year. Over 75% began offering mifepristone/misoprostol abortions within 5 months of the start of mifepristone distribution. Almost all (99%) reported using mifepristone/misoprostol regimens, with most offering one or more evidence-based alternative regimens (83%); a few (4%) used the FDA-approved regimen.nnnCONCLUSIONnAfter FDA approval of mifepristone, NAF member facilities rapidly adopted evidence-based mifepristone/misoprostol regimens.

Home-based versus clinic-based self-sampling and testing for sexually transmitted infections in Gugulethu, South Africa: randomised controlled trial.

Objectives: To test whether more women are screened for sexually transmitted infections when offered home-based versus clinic-based testing and to evaluate the feasibility and acceptability of self-sampling and self-testing in home and clinic settings in a resource-poor community. Methods: Women aged 14–25 were randomised to receive a home kit with a pre-paid addressed envelope for mailing specimens or a clinic appointment, in Gugulethu, South Africa. Self-collected vaginal swabs were tested for gonorrhoea, chlamydia and trichomoniasis using PCR and self-tested for trichomoniasis using a rapid dipstick test. All women were interviewed at enrolment on sociodemographic and sexual history, and at the 6-week follow-up on feasibility and acceptability. Results: 626 women were enrolled in the study, with 313 in each group; 569 (91%) completed their 6-week follow-up visit. Forty-seven per cent of the women in the home group successfully mailed their packages, and 13% reported performing the rapid test and/or mailing the kit (partial responders), versus 42% of women in the clinic group who kept their appointment. Excluding partial responders, women in the home group were 1.3 (95% CI 1.1 to 1.5) times as likely to respond to the initiative as women in the clinic group. Among the 44% who were tested, 22% tested positive for chlamydia, 10% for trichomoniasis, and 8% for gonorrhoea. Conclusions: Self-sampling and self-testing are feasible and acceptable options in low-income communities such as Gugulethu. As rapid diagnostic tests become available and laboratory infrastructure improves, these methodologies should be integrated into services, especially services aimed at young women.

Prevalence, distribution and correlates of endocervical human papillomavirus types in Brazilian women

We determined the prevalence, distribution and correlates of human papillomavirus (HPV) types in 386 mixed-income, sexually active women in São Paulo, Brazil. Endocervical samples were tested for HPV DNA with L1 primers MY09 and MY11; negative and indeterminate samples were retested using GP 5+/6+ consensus primers. HPV was detected in 35% of all women; high-risk/probable high-risk types in 20%; low-risk types in 7%; and an indeterminate type in 10%. Twenty-five HPV types were found overall: 17 (probable) high-risk types and eight low-risk types. Approximately one-third (29%) of women with HPV infection were positive for type 16 or 18 and 36% were positive for types 6, 11, 16 or 18. The presence of (probable) high-risk HPV was associated with younger age, more lifetime sex partners and abnormal vaginal flora. Additional studies mapping the distribution of HPV types worldwide are necessary to prepare for vaccination programmes and direct future vaccine development.

A comparison of two methods of partner notification for sexually transmitted infections in South Africa: patient-delivered partner medication and patient-based partner referral.

The objective of this study was to determine acceptability and feasibility of patient-based partner referral (PBPR) and patient-delivered partner medication (PDPM) among female sexually transmitted infection (STI) patients in a community-based STI screening study. Women were randomized to STI screening at home or at a clinic. STI patients could choose between PBPR and PDPM. Six-week follow-up interviews, and in-depth interviews, were conducted. STI prevalence was high. Most of the 106 women with an STI chose PDPM, mainly because partners would not have time or would not want to attend a clinic, and to ensure that partners received treatment. Nearly all partners reportedly took medication (94; 89% took it in front of the woman) or went to a clinic for treatment (92%). No adverse events were reported. Good communication emerged as the key to successful partner notification. In conclusion, PDPM could be used as a strategy to improve STI treatment coverage.

Early diagnosis and correlations of sexually transmitted infections among women in primary care health services

INTRODUCTIONnSexually Transmitted Infections (STIs) in women remain a public health challenge due to high prevalence, difficulties to implement early diagnosis strategies and high rates of complications.nnnOBJECTIVEnIdentify the prevalence of STIs among users of a primary health care clinic in São Paulo.nnnMETHODSnWomen, 18 to 40 years of age, were invited to self-collect vaginal specimens to be tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by Polymerase Chain Reaction (PCR). Women were also invited to answer a demographic and sexual history questionnaire, either on the computer or face-to-face.nnnRESULTSnThe prevalence of STIs obtained from the 781 women included in the study was: Chlamydia trachomatis: 8.4%, Neisseria gonorrhoeae: 1.9%, and Trichomonas vaginalis: 3.2%. Thirteen percent tested positive for at least one out of the three STIs. The variables associated independently with a higher risk of STIs were: age under 20-years-old, more than two lifetime sexual partners, and self-perception of STI risk. The use of condoms as a contraceptive method proved to be a protective factor.nnnCONCLUSIONnThe high prevalence found among these women indicates the need for the implementation of STI screening strategies in primary care settings in Brazil.