Judith A. Fortney

A dosing study of nonoxynol-9 and genital irritation.

The objective of the study was to assess the symptoms and signs of genital irritation produced by different frequencies of nonoxynol-9 (N-9) use. Thirty-five women were randomized to each of 5 groups and used a vaginal suppository for 2 weeks. Group 1: N-9 once every other day; Group 2: N-9 once a day; Group 3: N-9 twice a day; Group 4: N-9 4 times a day; and Group 5: placebo 4 times a day. Study women were examined at admission, one week and 2 weeks with a colposcope for erythema and epithelial disruption, and were interviewed about vaginal itching and burning. The rates of reported symptoms for N-9 users were not significantly different from that of placebo users. The rate of epithelial disruption for women using N-9 every other day was essentially the same as that of women using placebo. The rates of epithelial disruption for women using N-91/day and 2/day were 2.5 times greater than that of placebo users. The rate of epithelial disruption for women using N-9 4/day was five times greater than that of placebo users. Genital irritation was located primarily on the vagina or cervix, and vulvitis was not a significant problem. Women who infrequently use N-9 products may not experience an increase in genital irritation. Women who choose to use N-9 frequently may experience an increase in epithelial disruption.

The postpartum period: the key to maternal mortality

Objectives: To assess postpartum care at an international level, we reviewed published literature on postpartum maternal deaths. Methods: Meta‐analysis was used to summarize the literature reviewed. Postpartum deaths in developing countries were compared with those in the United States. Results: In both developing countries and the United States, >60% of maternal deaths occurred in the postpartum period; 45% of postpartum deaths occurred within 1 day of delivery, >65% within 1 week, >80% within 2 weeks. In developing countries, 80% of postpartum deaths caused by obstetric factors occurred within 1 week. Conclusions: The first 24 h postpartum and the first postpartum week is the high risk of postpartum deaths, and the risk remains significant until the second week after delivery. In developing countries, hemorrhage, pregnancy‐induced hypertension complications, and obstetric infection are commonest causes of postpartum deaths. We suggest primary prevention, early detection, and secondary prevention of postpartum deaths.

The importance of family planning in reducing maternal mortality.

Maternal mortality in many developing countries remains at distressingly high levels despite improvements in hospital obstetrics. WHO estimates that 1/2 million maternal deaths occur each year, 99% of which are in developing countries. While many people expect that widespread acceptance of family planning will bring down levels of maternal mortality, some analyses have claimed disappointing reductions, though others were more encouraging. The primary reason for this discrepancy lies in the choice of measure of maternal mortality, compounded somewhat by a confusion in terminology. Maternal mortality can be measured by: 1) the number of maternal deaths; 2) the maternal mortality ratio; 3) the maternal mortality rate; or 4) the lifetime risk of death in childbirth. Family planning use influences the maternal mortality ratio only to the extent that it reduces the proportion of pregnancies to high-risk women. The maternal mortality rate can be substantially influenced by the prevalence of contraception, but it is primarily the reduction in the number of births, per se, that exerts the influence. The choice of measure should be determined by the issue being addressed, and which of the 2 determinants of maternal mortality (obstetric risk or prevalence of pregnancy) is the focus. Current levels of maternal mortality in the developed countries have been achieved only with both good obstetric care and with low fertility. In developing countries today, modern obstetric care is often available only in a few teaching hospitals, but family planning programs are feasible even in remote areas. While implementing family planning programs is not easy, it is more feasible than the implementation of significant improvements in the quality and availability of obstetric care. The contribution of family planning to lower maternal mortality and morbidity should not be underestimated.

Reproductive mortality in two developing countries.

Reproductive mortality includes mortality attributable to pregnancy, termination of pregnancy, childbirth and its sequelae, and contraception. Reproductive mortality has been estimated for the United Kingdom, the United States, and for states of the US. However, it has not previously been measured for developing countries, where maternal mortality often remains distressingly high. This paper reports on data from one governorate of Egypt, where reproductive mortality was 46 per 100,000 married women ages 15-49 (2.2 per cent of this was attributable to contraception), and one province of Indonesia, where reproductive mortality was 70 per 100,000 (of which 1.4 per cent was due to contraception). In both locations, complications of pregnancy and childbirth were a leading cause of death in the age group studied (the first cause in Indonesia, second in Egypt). Contraceptive prevalence was 24 per cent of married women ages 15-49 in Egypt and 48 per cent of this age group in Indonesia.

Moderate physical activity and bone density among perimenopausal women.

We examined the association between physical activity and bone mineral density (BMD) among 352 perimenopausal women. A personal activity computer was used to estimate the daily energy expenditure on physical activity. BMD was measured by photon absorptiometry at the lumbar spine, midradius, and distal radius. Multiple linear regression, controlling for other factors, indicated that physical activity was positively and significantly associated with BMD at all sites. Moderate physical activity has beneficial effects on BMD among perimenopausal women.

Contraceptive use and HIV infection in Kenyan family planning clinic attenders

This pilot study aimed to determine the feasibility of a larger study of contraception and risk of HIV infection in women. We also measured risk factors for and occurrence of HIV infection in the participants. A cohort of 1537 seronegative women attending a family planning clinic in Nairobi, Kenya was enrolled and followed for up to 12 months per woman. HIV testing was done quarterly. A nested case-control analysis was done with seroconverting women (cases) and 3 matched controls per case, who had detailed interviews and received physical examinations and STD tests. The prevalence of HIV at enrolment was 6.1%; seropositive women were excluded from further analysis. The 12-month life-table cumulative incidence of HIV was 2.1 per 100 women (95% confidence interval [CI] 1.1-3.2). In the nested case-control analysis (17 cases and 51 controls), the crude odds ratio of HIV infection comparing oral contraceptive (OC) users with other women was 3.5 (95% CI 0.8- 21.5), which persisted after control for single confounders at a time. The putative association between OC use and HIV infection is critical to public health policy, yet no study has been conducted specifically to measure it, yielding weak and conflicting evidence. We intend to conduct a larger study with a similar design as the current pilot study, which confirmed the feasibility or a more definitive project.

Maternal mortality in Indonesia and Egypt

Twenty‐three percent of deaths to women of reproductive age (15–49 years) in Bali, Indonesia and Menoufia, Egypt were due to maternal causes. Among the younger women, the percentage was even higher. In both areas complications of pregnancy and childbirth were a leading cause of death (the first cause in Bali, the second in Menoufia). In both sites, postpartum hemorrhage was the most common cause of maternal death. Relative to the United States, the number of maternal deaths per 100 000 live births was 20 times higher in Menoufia and 78 times higher in Bali. Families of women of reproductive age who died were interviewed about the conditions leading to death and other characteristics of the deceased. Completed histories were reviewed by a Medical Panel who were able to assign a cause of death in more than 90% of cases. Two‐thirds of the maternal deaths occurred to women who were over 30 and/or who had 3 children — the usual targets of family planning programs. Other possible intervention strategies include antenatal outreach programs, training of traditional birth attendants, and better hospital management of obstetric emergencies.

Puerperal sepsis and maternal mortality: what role can new technologies play?

Objective: To identify new and underutilized technologies to reduce maternal mortality related to puerperal sepsis in developing countries. Method: Review of current medical literature. Result: The literature indicates that infection‐control protocols and evidence‐based procedures—including prophylactic antibiotics for cesarean section or preterm rupture of membranes, and updated antibiotic regimens—should be widely adopted. Devices such as hand rubs, needle‐disposal systems, and rapid microbiological diagnostic tests can improve compliance and efficiency. Operational research on promising developments like vaginal cleansing with antiseptics, vitamin A supplementation, and prophylactic antibiotics in high‐risk women is needed. Conclusion: Sepsis management continues to depend on good implementation of established technologies. Program‐based approaches are required to improve uptake.

Accidental burn deaths to Egyptian women of reproductive age.

Among women of reproductive age in Menoufia, Egypt, deaths from burns constitute a major public health problem. Burns account for 9 per cent of the deaths occurring to women aged 15-49, and were the third cause of death (after disease of the circulatory system and complications of pregnancy and childbirth). Nearly two-thirds of the burns were caused by kerosene cooking stoves. The data were obtained from a population-based survey of all deaths to women of reproductive age. There were 1691 deaths from all causes during the 3 years of the study, 152 of these were due to burns. Information on the cause of death was gathered from interviews with surviving family members; interviews were reviewed by physicians and a cause of death established. Although hospital-based studies provide valuable information for the management of burn injuries presenting for treatment, establishing rates of injury, comparing the incidence in one population group relative to another, or comparing the incidence of burns relative to other forms of injury requires a population-based study.

The effect of birth interval on perinatal survival and birth weight

Abstract Although the effect of a short birth interval on the first child in a pair has received attention in the literature, the effect on the second child has received less. In this article the authors investigate the complex set of relationships between birth interval, maternal age and parity, and their effects on the birth weight and survival of the later-born child. The data consist of 12,995 singleton births to women of parity two or higher during1977 and 1978 in a single hospital. The outcome of the previous pregnancy is controlled by restricting the analysis to women whose previous pregnancy ended in a live infant who is still living at the time of the index birth. The effect of birth interval on birth weight and on survival is examined simultaneously(via logistic regression), with the effects of maternal age and parity. The risks of adverse outcomes as a function of birth interval are estimated by adjusted odds ratios. After adjusting for maternal age and parity, interval was found to be an important precursor of both perinatal mortality and low birth weight. At all levels of maternal age and parity, babies born during a 9- to 12-month birth interval are at greater risk of low birth weight and/or perinatal mortality than babies born after a longer birth interval.