Jillian T. Henderson

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the United States. OBJECTIVE To systematically review the effectiveness, diagnostic accuracy, and harms of screening for CRC. DATA SOURCES Searches of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2008, through December 31, 2014, with surveillance through February 23, 2016. STUDY SELECTION English-language studies conducted in asymptomatic populations at general risk of CRC. DATA EXTRACTION AND SYNTHESIS Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Colorectal cancer incidence and mortality, test accuracy in detecting CRC or adenomas, and serious adverse events. RESULTS Four pragmatic randomized clinical trials (RCTs) evaluating 1-time or 2-time flexible sigmoidoscopy (n = 458,002) were associated with decreased CRC-specific mortality compared with no screening (incidence rate ratio, 0.73; 95% CI, 0.66-0.82). Five RCTs with multiple rounds of biennial screening with guaiac-based fecal occult blood testing (n = 419,966) showed reduced CRC-specific mortality (relative risk [RR], 0.91; 95% CI, 0.84-0.98, at 19.5 years to RR, 0.78; 95% CI, 0.65-0.93, at 30 years). Seven studies of computed tomographic colonography (CTC) with bowel preparation demonstrated per-person sensitivity and specificity to detect adenomas 6 mm and larger comparable with colonoscopy (sensitivity from 73% [95% CI, 58%-84%] to 98% [95% CI, 91%-100%]; specificity from 89% [95% CI, 84%-93%] to 91% [95% CI, 88%-93%]); variability and imprecision may be due to differences in study designs or CTC protocols. Sensitivity of colonoscopy to detect adenomas 6 mm or larger ranged from 75% (95% CI, 63%-84%) to 93% (95% CI, 88%-96%). On the basis of a single stool specimen, the most commonly evaluated families of fecal immunochemical tests (FITs) demonstrated good sensitivity (range, 73%-88%) and specificity (range, 90%-96%). One study (n = 9989) found that FIT plus stool DNA test had better sensitivity in detecting CRC than FIT alone (92%) but lower specificity (84%). Serious adverse events from colonoscopy in asymptomatic persons included perforations (4/10,000 procedures, 95% CI, 2-5 in 10,000) and major bleeds (8/10,000 procedures, 95% CI, 5-14 in 10,000). Computed tomographic colonography may have harms resulting from low-dose ionizing radiation exposure or identification of extracolonic findings. CONCLUSIONS AND RELEVANCE Colonoscopy, flexible sigmoidoscopy, CTC, and stool tests have differing levels of evidence to support their use, ability to detect cancer and precursor lesions, and risk of serious adverse events in average-risk adults. Although CRC screening has a large body of supporting evidence, additional research is still needed.

Low-Dose Aspirin for Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force

Preeclampsia is a leading cause of maternal death, affecting 2% to 8% of pregnancies globally (1, 2). It affected 3.8% of U.S. deliveries in 2010, and the rate of severe preeclampsia has increased over the past 3 decades (3). Perinatal mortality is nearly 2 times higher in pregnancies affected by preeclampsia (4), with 12% of maternal deaths due to the condition (5). Serious illness is more common, with more than one third of serious maternal morbidity and 15% of preterm births related to preeclampsia (6, 7). Preeclampsia is defined as hypertension (blood pressure 140/90 mm Hg) and proteinuria (presence of 0.3 g of protein in a 24-hour period) observed during the second half of pregnancy (>20 weeks of gestation) (8, 9). It is also classified as having severe features with any of the following: blood pressure above 160/110 mm Hg, thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, or cerebral or visual disturbances (9). Preeclampsia with or without severe features can evolve rapidly into eclampsia or the hemolysis, elevated liver enzymes, and low platelets syndrome, sometimes leading to systemic complications and maternal death (10, 11). Poor perinatal health outcomes are associated with preeclampsia, primarily due to increased risk for intrauterine growth restriction (IUGR) or medically initiated preterm delivery. Once preeclampsia develops, the only effective treatment is delivery, with serious neonatal harms when remote from term (<34 weeks of gestation). Current understanding of preeclampsia pathophysiology suggests that it may be a collection of syndromes with different precipitating factors and outcomes (12). Early in pregnancy, aberrations in placental development can result in placental ischemia and release of inflammatory and oxidative stress factors into the maternal bloodstream. In addition, even with normal placentation, preexisting hypertension, diabetes, and other inflammatory conditions (such as lupus) may activate systemic inflammatory and oxidative stress processes, as can twin or higher-order pregnancies. Accurate prediction of who will develop preeclampsia and have serious complications is not currently possible (1315). The most consistent predictors of high risk are previous preeclampsia, certain medical conditions (diabetes, chronic hypertension, renal disease, autoimmune diseases, and the antiphospholipid syndrome), and multifetal pregnancy (16). Moderately elevated risk for preeclampsia is associated with nulliparity (first birth), advanced maternal age (40 years), between-pregnancy interval of more than 10 years, high body mass index (35 kg/m2), and family history of preeclampsia (mother or sister). Risk factors with less consistent evidence include changes in paternity between pregnancies, history of migraine headaches (17, 18), and asthma (17, 1922). Predictive models combining various biomarkers, patient risk factors, and clinical readings hold promise but are not yet sufficiently validated for clinical use (10, 2325). Previous comprehensive systematic reviews have found antiplatelets (primarily low-dose aspirin) to be beneficial for the prevention of preeclampsia among women at heightened risk (26, 27). We conducted this systematic review to support the U.S. Preventive Services Task Force (USPSTF) in updating its 1996 recommendation, which is no longer active. Methods Detailed methods are outlined in our full evidence report (28). This review addressed 3 key questions (Appendix Figure 1). First, is low-dose aspirin effective for reducing adverse maternal and perinatal health outcomes among women at increased risk for preeclampsia? Second, is low-dose aspirin effective for preventing preeclampsia among women at increased risk for the condition? Third, are there harms to the woman and fetus associated with aspirin use during pregnancy? Appendix Figure 1. Analytic framework and key questions. ARDS = acute respiratory distress syndrome; HELLP = hemolysis, elevated liver enzymes, and low platelets. *Abbreviated list of health outcomes. See Appendix Table 2 for a full list. Data Sources and Searches In addition to considering all studies from the previous USPSTF review, we performed a comprehensive search of MEDLINE, PubMed, the Database of Abstracts of Reviews of Effects, and the Cochrane Central Register of Controlled Trials for studies published between January 2006 and 1 June 2013. We also examined the reference lists from existing systematic reviews to identify potentially eligible studies, including an individual-patient data (IPD) meta-analysis published by the Perinatal Antiplatelet Review of International Studies (PARIS) Collaboration (27) and a 2007 Cochrane review (26). We searched ClinicalTrials.gov for ongoing trials (May 2013). Between the last search date and this publication, we actively monitored published literature for potentially important new trials or other large observational studies directly relevant to our key questions; none were identified. Study Selection Two investigators independently reviewed abstracts and full-text articles for inclusion according to predetermined criteria. We resolved discrepancies through consensus with a third investigator. To evaluate benefits of aspirin prophylaxis, we included any study that used a risk selection approach aimed at achieving a sample of women at high risk for preeclampsia. The trials could define risk on the basis of medical history, pregnancy characteristics, or clinical measurements known to be associated with risk for the condition. Although preeclampsia occurs more often in first births than in subsequent ones, prevalence rates are relatively low (approximately 4%) compared with other high-risk groups. Because aspirin treatment based only on this risk factor has not been supported, trials with nulliparity as the sole risk factor were not included for evaluation of benefits. We used broader inclusion criteria to identify possible harms of aspirin exposure during pregnancy. The trials of women at high risk were combined with trials of women at low or average risk exposed to daily low-dose aspirin. Large prospective observational studies were also included to assess harms but were not included in pooled analyses. We included interventions that compared patients receiving 50 to 150 mg of aspirin with a placebo or no treatment group and excluded studies of nonaspirin antiplatelet medications or aspirin combined with another active substance. We also excluded studies that we rated as poor-quality on the basis of the USPSTF quality rating standards (29) and studies not published in English. Data Extraction and Quality Assessment Two investigators critically appraised all included studies independently using the USPSTFs design-specific criteria (29), which we supplemented with the National Institute for Health and Care Excellence methodology checklists (30) and the Newcastle-Ottawa Scale (31). According to the USPSTF criteria, a good-quality study met all prespecified standards. A fair-quality study did not meet (or it was unclear whether it met) at least 1 criterion, but it also had no known limitation that could invalidate its results. A poor-quality study had a single fatal flaw or multiple important limitations that could seriously bias its results. Discrepancies were resolved through discussion of identified limitations and consultation with a third investigator, if necessary. One investigator extracted study details and results, and a second investigator reviewed the abstracted information. Data Synthesis and Analysis We used the metan procedure in Stata, version 11.2 (StataCorp, College Station, Texas), for all reported meta-analyses and the metaan procedure for sensitivity analyses (32). For dichotomous outcomes, we entered the number of events and nonevents and estimated pooled random-effects risk ratios by using the DerSimonianLaird method for all outcomes, except those in which fewer than 10% of the participants had the event (33), for which we used a fixed-effects MantelHaenszel model (34). We also included prediction intervals in forest plots of random-effects models, which provided an estimate of where the effect size from 95% of newly conducted trials would fall, assuming that the between-study variability in the included trials held for new trials (35). The prediction intervals are shown on the forest plots by the horizontal lines that extend from the diamond representing the 95% CI of the pooled estimate. Potential sources of heterogeneity in effect size by aspirin timing, dosage, and preeclampsia risk determination were identified a priori and explored using meta regression and visual inspection of sorted forest plots. We used the I 2 and chi-square statistics to assess statistical heterogeneity. To evaluate small-study effects, we examined funnel plots and used the Begg or Peter test depending on the outcome distribution (36, 37). We used profile likelihood estimation to conduct sensitivity analyses for the pooled effects because the DerSimonianLaird method can overestimate CI precision in meta-analysis, particularly when fewer than 10 studies or when smaller studies with few events are pooled (38). Role of the Funding Source This study was funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract to support the work of the USPSTF. Members of the USPSTF and the AHRQ medical officer assisted in the development of the reviews scope. Approval from AHRQ was required before the manuscript could be submitted for publication, but the authors are solely responsible for its content and the decision to submit it for publication. Results Our literature search yielded 544 unique citations. From these, we reviewed the full text of 75 articles. Twenty-three studies (27 articles) met our inclusion criteria (Appendix Figure 2 and Appendix Table 1). Appendix Figure 2. Summary of evidence search and selection. The diagram excludes 51 RefMan (Thomson Reuters, Philadelph

Racial Differences in Vasectomy Utilization in the United States: Data From the National Survey of Family Growth

OBJECTIVES To explore whether health care, socioeconomic, or personal characteristics account for disparities observed in the utilization of vasectomy. More than 500,000 vasectomies are performed annually in the United States. The safety and efficacy of vasectomy make it a good family planning option, yet the factors related to use of male surgical sterilization are not well understood. In this analysis, we examined differences in vasectomy rates according to factors such as race and socioeconomic status. METHODS We analyzed data from the male sample of the 2002 National Survey of Family Growth to examine the use of vasectomy among the sample of men aged 30-45 (n = 2161). Demographic, socioeconomic, and reproductive characteristics were analyzed to assess associations with vasectomy. RESULTS About 11.4% of men aged 30-45 years reported having a vasectomy, representing approximately 3.6 million American men. Although 14.1% of white men had a vasectomy, only 3.7% of black and 4.5% of Hispanic men reported undergoing vasectomy. On multivariate analysis, a significant difference in the odds of vasectomy by race/ethnicity remained, with black (odds ratio = 0.20, 0.09-0.45) and Hispanic men (odds ratio = 0.41, 0.18-0.95) having a significantly lower rate of vasectomy independent of demographic, partner, and socioeconomic factors. Having ever been married, fathering 2 or more children, older age, and higher income were the factors associated with vasectomy. CONCLUSIONS After accounting for reproductive history, partner, and demographic characteristics, black and Hispanic men were less likely to rely on vasectomy for contraception. Further research is needed to identify the reasons for these race/ethnic differences and to identify factors that impede minority mens reliance on this means of fertility control.

Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force

Cigarette smoking and exposure to smoke result in more than 480000 premature deaths in the United States every year, along with substantial illness (1, 2). Despite considerable progress in tobacco control over the past 50 years, in 2013, an estimated 17.8% of U.S. adults (3) and 15.9% of pregnant women aged 15 to 44 years were current cigarette smokers (4). Many tools are available to help smokers quit, including counseling by health care providers, telephone- and print-based interventions, computer and text-messaging interventions, and pharmacologic agents (that is, nicotine replacement therapy [NRT], bupropion hydrochloride sustained release [bupropion], and varenicline). In 2009, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its 2003 recommendation that clinicians ask all adults about tobacco use and provide interventions for cessation for those who use tobacco products (grade A recommendation) (5). The original USPSTF recommendation (2003) and reaffirmation (2009) were based on the Public Health Services clinical practice guidelines on treating tobacco use and dependence (6, 7). Because there were no plans to update the Public Health Service report, we undertook the current review to assess the benefits and harms of behavioral and pharmacologic interventions for tobacco cessation in adults, including pregnant women, to assist the USPSTF in updating its 2009 recommendation. Because of the rapid increase in the use of electronic nicotine delivery systems (ENDS) and the vigorous debate about the public health effect of these devices and their role in smoking cessation (813), our review also synthesized the primary trial evidence on the efficacy and safety related to this technology as a means for quitting conventional smoking. Methods We relied primarily on a review of reviews method for this update. We did not replicate quality rating or data abstraction for original studies or replicate review-specific analyses. However, we decided a priori to conduct a de novo search for primary evidence related to the effectiveness and safety of ENDS. In addition, we did a bridge search for evidence related to pharmacotherapy interventions among pregnant women because of the limited number of studies included in the available systematic reviews and the length of time that had elapsed since their last search dates. We developed an analytic framework and 3 key questions with input from the USPSTF (Appendix Figure 1). The final version of the framework and key questions reflects both USPSTF and public input. The full report provides detailed methods (14). Appendix Figure 1. Analytic framework. KQ = key question. Data Sources and Searches We searched the following databases for relevant reviews from January 2009 to 1 August 2014: PubMed, PsycInfo, Cochrane Database of Systematic Reviews, Health Technology Assessment database, and Database of Abstracts of Reviews of Effects of the Centre for Reviews and Dissemination. We also searched the following organizational Web sites: the Agency for Healthcare Research and Quality, the British Medical Journal Clinical Evidence (through 7 August 2013), the Canadian Agency for Drugs and Technologies in Health, Guide to Community Preventive Services, the Institute of Medicine, the National Institute for Health and Clinical Excellence, the National Health Service Health Technology Assessment Programme, and the Surgeon General. We supplemented our searches with suggestions from experts. We searched PubMed for primary evidence related to ENDS through 1 March 2015 and for pharmacotherapy interventions among pregnant women through 15 August 2014 (the full report outlines the search strategies for these 2 searches [14]). Study Selection Two investigators independently reviewed all identified abstracts and dually reviewed full-text articles against prespecified eligibility criteria (14). We resolved disagreements through discussion. We included systematic reviewswith or without meta-analysisthat examined the effectiveness of interventions for tobacco cessation for adults, including pregnant women, and were linked to primary care or took place in a general adult population. We excluded nonsystematic meta-analyses and narrative reviews. We also excluded reviews that focused on reduction of tobacco harms, interventions for relapse prevention, or cessation medications that were not approved by the U.S. Food and Drug Administration as first-line medications for cessation (such as nortriptyline). We included only the most recent version of updated reviews. We outlined separate selection criteria when considering primary evidence related to ENDS and pharmacotherapy among pregnant women, as described in the full report (14). Data Extraction and Quality Assessment At least 2 independent reviewers rated the quality of all included systematic reviews using a slightly modified version of the Assessment of Multiple Systematic Reviews tool (15, 16) (see the full report for modifications and methods for determining the overall quality rating of individual reviews [14]). We excluded all poor-quality studies (17). One reviewer completed primary data abstraction, and a secondary reviewer checked all data for accuracy and completeness. Data Synthesis and Analysis When we found several fair- and good-quality reviews that met the inclusion criteria in a given population and intervention subgroup, we applied criteria (Appendix Table 1) to identify 1 or more reviews that represented the most current and applicable evidence to serve as the basis for the main findings (called primary reviews). We reviewed the remaining reviews for complementary or discordant findings. When we encountered discordant bodies of evidence, we sought explanations for these differences by examining the eligibility criteria and included studies within each review. Appendix Table 1. Criteria for Choosing the Primary Existing Systematic Reviews We used the pooled point estimates presented in the included reviews when appropriate. We did not reanalyze any of the individual study evidence. We evaluated the appropriateness of meta-analytic procedures and used our technical judgment to interpret pooled analyses accounting for limitations or concerns around heterogeneity, statistical approaches (18, 19), and other factors. Role of the Funding Source This review was funded by the Agency for Healthcare Research and Quality. Agency staff provided technical oversight for the project. Liaisons from the USPSTF helped resolve issues around the reviews scope but were not involved in its conduct. Results We reviewed 638 abstracts and 114 full-text reviews for possible inclusion (Appendix Figure 2). We identified 54 systematic reviews that met our eligibility criteria (2073), and 22 of these served as the basis for the primary findings (Table 1). In general, results across all included reviews were consistent within each population and intervention grouping. Our results are organized by outcomes and subcategories by population and interventions. Eleven of the 54 included reviews synthesized evidence on interventions among specific subpopulations of adults (such as persons with depression and young adults) that are not included here but appear in detail in the full report (14). Appendix Figure 2. Summary of evidence search and selection. * 2 studies included both adults and pregnant women. Reviews can be counted in multiple intervention areas. Table 1. Characteristics of Included Systematic Reviews (n =54), by Population, Intervention, and Last Search Date Behavioral Interventions Among Adults Eleven reviews served as primary reviews examining the effects of behavioral interventions for smoking cessation among the general adult population (Table 1) (21, 22, 31, 37, 55, 58, 60, 61, 67, 71, 78). Health and Cessation Outcomes Data on health outcomes after behavioral interventions were limited to 1 study (79) that was reported in 1 review (58) (Table 2). This study reported no statistically significant differences in rates of total mortality, coronary disease mortality, and lung cancer incidence and mortality at 20-year follow-up among men at high risk for cardiorespiratory disease (n=1445) (80). However, at 33-year follow-up, there were significantly fewer deaths from respiratory illnesses among participants who received an intervention than control participants (58). Table 2. Summary of Evidence for the General Adult Population Several behavioral interventions increased smoking cessation at 6 months or more, including physician- (58) and nurse-delivered (55) counseling interventions, tailored self-help print materials (37), and telephone counseling (60), when compared with minimal intervention or usual care (Table 2 and Appendix Table 2). Smokers who were offered cessation advice by a physician, for example, were 76% more likely to have quit at 6 months or more than those who received no advice or usual care (risk ratio [RR], 1.76 [95% CI, 1.58 to 1.96]; I 2=40%; 28 trials; n=22239) (58). Both minimal and intensive advice (>20 minutes, additional materials beyond a brochure, or >1 follow-up visit) showed statistically significant increases in cessation rates when compared with control participants who did not receive advice. Direct comparisons between intensive and minimal advice in 15 trials suggested that more intensive advice offered a significant advantage (RR, 1.37 [CI, 1.20 to 1.56]; I 2=32%; 15 trials; n=9775) (58). Appendix Table 2. Summary of Smoking Abstinence Results From Reviews of Behavioral Counseling and Pharmacotherapy Interventions for Smoking Cessation Among Adults, by Type of Intervention A separate meta-analysis of 38 randomized, controlled trials (RCTs) done among more than 15000 smokers found a small relative benefit of adjunctive behavioral support to pharmacotherapy when compared with pharmacotherapy alone (RR, 1.16 [CI, 1.09 to 1.24]) (61). Cessation rates were relatively high in both the intervention (21.4%) and control (18

Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings.

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

A Randomized Study of a Pregnancy and Disease Prevention Intervention for Hispanic Couples

CONTEXT Many Hispanic women are at elevated risk for HIV infection because of the sexual behavior of their male partner. Yet, couple-based risk-reduction interventions for this population have not been developed and scientifically evaluated. METHODS A sample of 146 Hispanic couples who received either a risk reduction intervention or the community educational standard of care were followed up at three months (men and women) and six months (women only) to measure the consistency of both condom use and effective contraceptive use, and the frequency of unprotected vaginal sex. Analyses were conducted to identify differences between the two groups at baseline and follow-up interviews, and changes over time. RESULTS At follow-up, the two groups did not differ on any risk-related outcomes; over time, both groups increased the reported consistency of condom use and of use of effective contraceptive methods, and reduced their frequency of unprotected sex. CONCLUSIONS If further research confirms that simply bringing couples together for a single-session, culturally appropriate risk reduction intervention helps them adopt protective behaviors, more intensive (and costly) interventions may not be necessary.

Do Depression and Low Self‐Esteem Follow Abortion Among Adolescents? Evidence from a National Study

CONTEXT A 2008 report by the American Psychological Association found no evidence that an induced abortion causes mental health problems in adult women. No conclusions were drawn with respect to adolescents because of a scarcity of evidence. METHODS Data from the National Longitudinal Study of Adolescent Health were used to examine whether abortion in adolescence was associated with subsequent depression and low self-esteem. In all, 289 female respondents reported at least one pregnancy between Wave 1 (1994-1995) and Wave 2 (1996) of the survey. Of these, 69 reported an induced abortion. Population-averaged lagged logistic regression models were used to assess associations between abortion and depression and low self-esteem within a year of the pregnancy and approximately five years later, at Wave 3 (2001-2002). RESULTS Abortion was not associated with depression or low self-esteem at either time point. Socioeconomic and demographic characteristics did not substantially modify the relationships between abortion and the outcomes. CONCLUSIONS Adolescents who have an abortion do not appear to be at elevated risk for depression or low self-esteem in the short term or up to five years after the abortion.

Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners

OBJECTIVE Nurse practitioners (NPs) provide frontline care in womens health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants. METHOD A US nationally representative sample of nurse practitioners in primary care and womens health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use. RESULTS Two-thirds of womens health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in womens health and 10% in primary care. Half of NPs desired training in these methods. CONCLUSION Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Effects of abortion legalization in Nepal, 2001-2010.

Background Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. Methods We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001–2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001–2003), early implementation (2004–2006), and later implementation (2007–2010). Results 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). Conclusion Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women’s health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Behavioral Sexual Risk Reduction Counseling in Primary Care to Prevent Sexually Transmitted Infections: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

The Centers for Disease Control and Prevention estimates that approximately 20 million new cases of sexually transmitted infections (STIs) occur each year in the United States, half of which are among persons aged 15 to 24 years (1). In 2003 and 2004, 38% of sexually active female adolescents aged 14 to 19 years had an STI (2). In 2010, the inflation-adjusted annual direct medical costs of STIs were estimated to be