Ilana Dzuba

Factors affecting utilization of cervical cancer prevention services in low-resource settings

Strategies for introducing or strengthening cervical cancer prevention programs must focus on ensuring that appropriate, cost-effective services are available and that women who most need the services will, in fact, use them. This article summarizes the experiences of research projects in Bolivia, Peru, Kenya, South Africa, and Mexico. Factors that affect participation rates in cervical cancer prevention programs are categorized in three sections. The first section describes factors that arise from prevailing sociocultural norms that influence womens views on reproductive health, well being, and notions of illness. The second section discusses factors related to the clinical requirements and the type of service delivery system in which a woman is being asked to participate. The third section discusses factors related to quality of care. Examples of strategies that programs are using to encourage womens participation in cervical cancer prevention services are provided. This paper is available too at: http://www.insp.mx/salud/index.html.

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomised, non-inferiority trial

BACKGROUND Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin. METHODS In this double-blind, non-inferiority trial, 31 055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Vietnam (two secondary-level and three tertiary-level facilities). 809 (3%) women were diagnosed with post-partum haemorrhage and were randomly assigned to receive 800 mug misoprostol (n=407) or 40 IU intravenous oxytocin (n=402). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS All randomly assigned participants were analysed. Active bleeding was controlled within 20 min after initial treatment for 363 (89%) women given misoprostol and 360 (90%) given oxytocin (relative risk [RR] 0.99, 95% CI 0.95-1.04; crude difference 0.4%, 95% CI -3.9 to 4.6). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) women receiving misoprostol and 123 (31%) receiving oxytocin (RR 1.12, 95% CI 0.92-1.37). Shivering (152 [37%] vs 59 [15%]; RR 2.54, 95% CI 1.95-3.32) and fever (88 [22%] vs 59 [15%]; 1.47, 1.09-1.99) were significantly more common with misoprostol than with oxytocin. Six women had hysterectomies and two women died. INTERPRETATION Misoprostol is clinically equivalent to oxytocin when used to stop excessive post-partum bleeding suspected to be due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour.

Involving the community in cervical cancer prevention programs.

Underutilization of cervical cancer prevention services by women in the high‐risk age group of 30–60 years can be attributed to health service factors (such as poor availability, poor accessibility, and poor quality of care provided), to womens lack of information, and to cultural and behavioral barriers. The Alliance for Cervical Cancer Prevention (ACCP) partners have been working to identify effective ways to increase womens voluntary participation in prevention programs by testing strategies of community involvement in developing countries. The ACCP experiences include developing community partnerships to listen to and learn from the community, thereby enhancing appropriateness of services; developing culturally appropriate messages and educational materials; making access to high‐quality screening services easier; and identifying effective ways to encourage women and their partners to complete diagnosis and treatment regimens. Cervical cancer prevention programs that use these strategies are more likely to increase demand, ensure follow‐through for treatment, and ultimately reduce disease burden.

A strategic assessment of cervical cancer prevention and treatment services in 3 districts of Uttar Pradesh, India

BackgroundDespite being a preventable disease, cervical cancer claims the lives of almost half a million women worldwide each year. India bears one-fifth of the global burden of the disease, with approximately 130,000 new cases a year. In an effort to assess the need and potential for improving the quality of cervical cancer prevention and treatment services in Uttar Pradesh, a strategic assessment was conducted in three of the states districts: Agra, Lucknow, and Saharanpur.MethodsUsing an adaptation of stage one of the World Health Organizations Strategic Approach to Improving Reproductive Health Policies and Programmes, an assessment of the quality of cervical cancer services was carried out by a multidisciplinary team of stakeholders. The assessment included a review of the available literature, observations of services, collection of hospital statistics and the conduct of qualitative research (in-depth interviews and focus group discussions) to assess the perspectives of women, providers, policy makers and community members.ResultsThere were gaps in provider knowledge and practices, potentially attributable to limited provider training and professional development opportunities. In the absence of a state policy on cervical cancer, screening of asymptomatic women was practically absent, except in the military sector. Cytology-based cancer screening tests (i.e. pap smears) were often used to help diagnose women with symptoms of reproductive tract infections but not routinely screen asymptomatic women. Access to appropriate treatment of precancerous lesions was limited and often inappropriately managed by hysterectomy in many urban centers. Cancer treatment facilities were well equipped but mostly inaccessible for women in need. Finally, policy makers, community members and clients were mostly unaware about cervical cancer and its preventable nature, although with information, expressed a strong interest in having services available to women in their communities.ConclusionTo address gaps in services and unmet needs, state policies and integrated interventions have the potential to improve the quality of services for prevention of cervical cancer in Uttar Pradesh.

Advocating for cervical cancer prevention.

Cervical cancer is a significant health problem among women in developing countries. Contributing to the cervical cancer health burden in many countries is a lack of understanding and political will to address the problem. Broad‐based advocacy efforts that draw on research and program findings from developing‐country settings are key to gaining program and policy support, as are cost‐effectiveness analyses based on these findings. The Alliance for Cervical Cancer Prevention (ACCP) has undertaken advocacy efforts at the international, regional, national, and local levels to raise awareness and understanding of the problem (and workable solutions), galvanize funders and governments to take action, and engage local stakeholders in ensuring program success. ACCP experience demonstrates the role that evidence‐based advocacy efforts play in the ultimate success of cervical cancer prevention programs, particularly when new screening and treatment approaches—and, ultimately, radically new approaches such as a human papillomavirus vaccine—are available.

A participatory assessment to identify strategies for improved cervical cancer prevention and treatment in Bolivia

En este trabajo se evaluan la organizacion y disponibilidad de servicios de prevencion y tratamiento del cancer cervicouterino en cuatro de los nueve departamentos de Bolivia y se identifican estrategias de intervencion. De 2001 a 2002 un equipo multidisciplinario de 15 personas llevo a cabo en Bolivia una evaluacion que comprendio una revision bibliografica sobre el cancer cervicouterino en el pais, entrevistas semiestructuradas con 583 partes interesadas y 56 observaciones de servicios de salud de diversos niveles. En un taller celebrado despues del trabajo de campo se reunieron 60 lideres de todos los departamentos del pais para revisar los resultados y determinar su prioridad, y para elaborar recomendaciones basadas en las pruebas cientificas recaudadas con miras a fortalecer los servicios de prevencion del cancer cervicouterino. Bolivia tiene una de las tasas mas altas de cancer cervicouterino en el mundo. No obstante, no tiene ningun programa organizado ni tampoco ninguna estrategia destinada a lograr que el tamizaje del cancer cervicouterino alcance una cobertura minima de 80%, que es la meta establecida por el Ministerio de Salud y Prevision Social. Una buena parte de la poblacion carece de informacion sobre los servicios para la prevencion y el tratamiento de lesiones precancerosas, o no puede llegar a estos servicios con facilidad. Los proveedores de atencion sanitaria en el sector publico calculan que de 50 a 80% de las mujeres sometidas al tamizaje no regresan a su seguimiento porque no hay ningun sistema que garantice un seguimiento adecuado con fines de diagnostico o tratamiento. Muchos prestadores de atencion de salud desconocen que los frotis de Papanicolaou se usan para detectar lesiones precancerosas. Bolivia tiene una unidad establecida dentro del Ministerio de Salud y Prevision Social cuya funcion es crear, administrar y supervisar programas nacionales para la prevencion y el tratamiento del cancer cervicouterino. Dicha unidad, en coordinacion con las autoridades sanitarias en cada uno de los departamentos del pais, tambien busca fortalecer la imposicion de normas nacionales, actividades de capacitacion, e iniciativas comunitarias de tipo informativo o educativo. No obstante, los servicios de tamizaje no estan debidamente vinculados con los de diagnostico y tratamiento de lesiones precancerosas. Por anadidura, los servicios de diagnostico y tratamiento no siempre abundan o son accesibles. Si se han de mejorar los servicios y la atencion a la comunidad, es necesario llevar a cabo investigaciones, efectuar cambios programaticos y adoptar cambios de politicas a fin de fortalecer la planificacion y el proceso decisorio en conexion con los aspectos administrativos, tecnologicos, socioculturales y economicos del asunto.

Safety, efficacy and acceptability of outpatient mifepristone-misoprostol medical abortion through 70 days since last menstrual period in public sector facilities in Mexico City

Abstract Extensive evidence exists regarding the efficacy and acceptability of medical abortion through 63 days since last menstrual period (LMP). In Mexico City’s Secretariat of Health (SSDF) outpatient facilities, mifepristone-misoprostol medical abortion is the first-line approach for abortion care in this pregnancy range. Recent research demonstrates continued high rates of complete abortion through 70 days LMP. To expand access to legal abortion services in Mexico City (where abortion is legal through 12 weeks LMP), this study sought to assess the efficacy and acceptability of the standard outpatient approach through 70 days in two SSDF points of service. One thousand and one women seeking pregnancy termination were enrolled and given 200 mg mifepristone followed by 800 μg misoprostol 24–48 hours later. Women were asked to return to the clinic one week later for evaluation. The great majority of women (93.3%; 95% CI: 91.6–94.8) had complete abortions. Women with pregnancies ≤8 weeks LMP had significantly higher success rates than women in the 9th or 10th weeks (94.9% vs. 90.5%; p = 0.01). The difference in success rates between the 9th and 10th weeks was not significant (90.0% vs. 91.2%; p = 0.71). The majority of women found the side effects (82.9%) and the use of misoprostol (84.4%) to be very acceptable or acceptable. This study provides additional evidence supporting an extended outpatient medical abortion regimen through 10 weeks LMP. Résumé De nombreuses données existent sur l’efficacité et l’acceptabilité de l’avortement médicamenteux jusqu’à 63 jours depuis la date des dernières règles (DDR). Dans les centres ambulatoires du Secrétariat de la santé de Mexico (SSDF), l’avortement médicamenteux sous mifépristone et misoprostol est la méthode de première intention pour l’interruption de grossesses de cet âge gestationnel. Des recherches récentes montrent des taux élevés d’avortement complet jusqu’à 70 jours après la DDR. Pour élargir l’accès à des services d’avortement légal à Mexico (où l’avortement est autorisé jusqu’à 12 semaines après la DDR), cette étude a tenté d’évaluer l’efficacité et l’acceptabilité de la méthode ambulatoire standard jusqu’à 70 jours dans deux centres du SSDF. Mille et une femmes souhaitant avorter ont été recrutées et ont reçu 200 mg de mifépristone suivis de 800 μg de misoprostol 24–48 heures plus tard. Elles ont été invitées à revenir au centre une semaine après pour évaluation. Chez la grande majorité des patientes (93,3% ; IC 95% : 91,6–94,8), l’avortement était complet. Les femmes enceintes ≤8 semaines après la DDR avait des taux de réussite sensiblement plus élevés que les femmes à 9 ou 10 semaines (94,9% contre 90,5% ; p = 0,01). La différence dans les taux de réussite entre la 9e et la 10e semaine était non significative (90,0% contre 91,2% ; p = 0,71). La majorité des femmes ont jugé les effets secondaires (82,9%) et l’utilisation du misoprostol (84,4%) très acceptables ou acceptables. Cette étude fournit des données supplémentaires soutenant un régime étendu d’avortement médicamenteux en ambulatoire jusqu’à 10 semaines après la DDR. Resumen Existe extensa evidencia respecto a la eficacia y aceptabilidad del aborto con medicamentos hasta los 63 días desde la fecha de la última menstruación (FUM). En las unidades de salud ambulatorias de la Secretaría de Salud del Distrito Federal de México (SSDF), el aborto con medicamentos inducido con mifepristona-misoprostol es el enfoque de primera línea en los servicios de aborto para esta etapa de la edad gestacional. Recientes investigaciones demuestran continuas altas tasas de aborto completo hasta concluidos los 70 días desde la FUM. Con el fin de ampliar el acceso a los servicios de interrupción legal del embarazo en el Distrito Federal (donde el aborto es legal hasta las 12 semanas desde la FUM), este estudio buscó evaluar la eficacia y aceptabilidad del enfoque ambulatorio estándar hasta los 70 días en dos puntos de entrega de servicios de la SSDF. Mil y una mujeres que buscaban interrumpir su embarazo fueron inscritas y administradas una dosis de 200 mg de mifepristona seguida de 800 μg de misoprostol, 24 a 48 horas después. Se les pidió a las mujeres que regresaran a la clínica una semana después para la evaluación. La gran mayoría de las mujeres (93.3%; 95% IC: 91.6–94.8) tuvo un aborto completo. Las mujeres con embarazos ≤8 semanas desde la FUM tuvieron tasas de eficacia significantemente más altas que las mujeres en la novena o décima semanas (94.9% vs. 90.5%; p = 0.01). La diferencia en las tasas de eficacia entre la novena y décima semanas no fue significante (90.0% vs. 91.2%; p = 0.71). La mayoría de las mujeres encontraron que los efectos secundarios (82.9%) y el uso de misoprostol (84.4%) eran muy aceptables o aceptables. Este estudio ofrece evidencia adicional que respalda un régimen de aborto con medicamentos extendido hasta concluidas las 10 semanas desde la FUM para usuarias ambulatorias.

Medical abortion: A path to safe, high-quality abortion care in Latin America and the Caribbean

Abstract Background Abortion rates in Latin America and the Caribbean (LAC) are nearly triple those in Western Europe, due to less use of contraception and highly restrictive abortion laws. Women resort to clandestine and often unsafe methods to end unwanted pregnancies, exposing themselves to the risk of complications and mortality. Medical abortion (MA) presents a safer alternative. Objectives To present evidence of MAs contributions to reduced complications, describe strategies to enhance safe MA, and highlight existing barriers to access in LAC, while examining MAs role in newly legal abortion services. Results Substantial declines in abortion-related morbidity and mortality and lower costs of treating complications are observed in LAC with MA than with other self-induction methods. Telephone hotlines, telemedicine and harm reduction models enhance access to safer abortion and help reduce complication rates by facilitating information on MAs proper use. Misoprostol is registered in most LAC countries, but access is increasingly limited by regulations and cost. Conclusion Despite highly restrictive abortion laws in LAC, MA increases access to safer abortion. Yet, significant barriers remain and much more must be done to enhance use of modern contraceptive and safer abortion methods among women in the region.

Efficacy and acceptability of a mifepristone–misoprostol combined regimen for early induced abortion among women in Mexico City

To evaluate the experience of women receiving mifepristone–misoprostol for early induced abortion in public sector facilities in the Federal District of Mexico City.

O207 ROUTE OF ADMINISTRATION OF OXYTOCIN IN PREVENTION OF POSTPARTUM HEMORRHAGE

coverage also jumped significantly (17.5%, p < 0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes. Conclusions: Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in Ghana, and especially among the poor. This finding should be considered when evaluating the impact of the NHIS and in supporting the continuation and expansion of free delivery care.