Laura Reichenbach

Genital human papillomavirus infection among women in Bangladesh: findings from a population-based survey.

Background There has been no population-based study on human papillomavirus (HPV) prevalence or its genotypes in Bangladesh; a country eligible for GAVI funding for HPV vaccine. Methods We used baseline survey data of a prospective cohort study that was conducted in one urban and one rural area of Bangladesh. A total of 997 urban and 905 rural married women, aged 13 to 64 years, were enrolled in the baseline during July-December, 2011. Information was collected on socio-demographic characteristics and potential risk factors for HPV infection followed by gynecological examination and collection of endocervical samples using the cervical cytobrush (Digene cervical sampler). HPV DNA testing was done by Polymerase Chain Reaction (PCR) using a consensus primer set. Results Prevalence of any HPV infection was 7.7% with no significant difference between urban and rural women. Most common high-risk genotypes were HPV16, HPV66, HPV18, HPV45, HPV31 and HPV53. Urban women working as housemaids or garment workers were at higher risk of any HPV infection (OR = 2.15, 95% CI: 1.13–4.11) compared to housewives. Rural women whose husband lived overseas were almost two times more likely to have any HPV infection (OR = 1.93; 95% CI 1.05–3.55) compared to women whose husbands lived with them. Conclusion The prevalence of HPV infection among Bangladeshi women is similar to other regions of Asia. However, type-specific patterns are different. The study findings will inform the formulation of HPV vaccination policies in Bangladesh, monitoring the impact of vaccination programmes, and the identification of target populations for screening.

Measuring and monitoring quality of care in family planning: are we ignoring negative experiences?

Despite decades of emphasis on quality of care, qualitative research continues to describe incidents of poor quality client–provider interactions in family planning provision. Using an emerging framework on disrespect and abuse (D and A) in maternal health services, we reviewed the global published literature for quantitative tools that could be used to measure the prevalence of negative client experiences in family planning programs. The search returned over 7,000 articles, but only 12 quantitative tools included measures related to four types of D and A (non-confidential care, non-dignified care, non-consented care, or discrimination). We mapped individual measurement items to D and A constructs from the maternal health field to identify measurement gaps for family planning. We found significant gaps; current tools are not adequate for determining the prevalence or impact of negative client experiences in family planning programs. Programs need to invest in tools that describe all aspects of client experiences, including negative experiences, to increase accountability and maximize the impact of current investments in family planning programs.

“Side effects affected my daily activities a lot”: a qualitative exploration of the impact of contraceptive side effects in Bangladesh

Purpose In a country like Bangladesh that has made great progress in contraceptive use with one of the lowest levels of fertility and highest levels of contraceptive use, understanding what factors influence women’s decisions to discontinue a contraceptive method and not switch to a new method is critical in designing interventions and programs that will help enable Bangladesh to reach its FP2020 goals. Research on side effects has focused on physical manifestations like headaches, moodiness, abdominal pain, and menstrual irregularities. While physical effects alone may stop women from continuing a contraceptive method, less is known about how side effects influence women’s daily activities and lives. The purpose of this study is to understand the ways that side effects affect Bangladeshi women’s participation in different social settings. Methods Thirty-five in-depth interviews with married women who recently discontinued or switched to a different contraceptive method were conducted in Sylhet and Khulna Divisions. Interviews explored reasons for discontinuation including experience of side effects and impact of side effects on women’s lives. Results Key themes emerged including that side effects are not only experienced physically but are barriers to women’s participation in many aspects of their lives. The spheres of life that most commonly appeared to be influenced by side effects include religion, household, and sexual intimacy irrespective of method used or residence. Conclusion Family planning providers need to be aware of these additional consequences associated with contraceptive side effects to provide tailored counseling that recognizes these issues and helps women to mitigate them. For Bangladesh to achieve its FP2020 goals, understanding the broader context in which family planning decisions are made vis-à-vis side effects is critical to design programs and interventions that meet all the needs of women beyond just their fertility intentions.

Understanding the use of India's National Health Insurance Scheme for family planning and reproductive health services in Uttar Pradesh

Indias National Health Insurance Scheme, Rashtriya Swasthya Bima Yojana (RSBY), expands health services to families living below the poverty line by enrolling them into the scheme through selected health facilities. Use and reasons for nonuse of RSBY for family planning (FP) and reproductive health (RH) services have not been explored previously. This cross-sectional study explored the use of RSBY for FP/RH services at private health facilities, knowledge of FP/RH service availability, and factors influencing knowledge among RSBY enrolled families. A total of 726 women and 640 men from enrolled families living in 3 cities of Uttar Pradesh, India, were interviewed. Use of FP/RH services at private hospitals enrolled in the RSBY was 2%. Nearly 20% of respondents used FP or delivery services from unenrolled private hospitals but could have accessed these services through the scheme. Over 75% of respondents were unaware of FP/RH service availability through RSBY. Respondents with some education were more likely to have this knowledge, while poorer families were less likely to have this knowledge. Findings suggest that for RSBY to reach the most vulnerable families, efforts need to be made to better educate enrolled families about their entitlements and benefits of the scheme.

Mifepristone–misoprostol for menstrual regulation in public sector facilities in Bangladesh

To examine the use of mifepristone and misoprostol for menstrual regulation among Bangladeshi women attending public sector facilities.

Feasibility of patent and proprietary medicine vendor provision of injectable contraceptives: preliminary results from implementation science research in Oyo and Nasarawa, Nigeria

BACKGROUND Nigerian policymakers are debating task-shifting injectable contraceptive services to Patent and Proprietary Medicine Vendors (PPMVs). METHODOLOGY One hundred fifty-two PPMVs were trained to provide injectable contraceptives in Oyo and Nasarawa states. Data were collected before and 1, 3 and 9 months posttraining. χ2 tests were conducted to assess associations between survey time points. MAIN FINDINGS Few PPMVs had the necessary knowledge to provide injectables pretraining. A majority demonstrated increased knowledge after the training. Knowledge required for screening and counseling clients was lower than knowledge on administration. CONCLUSION PPMVs should be trained before providing injectable services. Additional research is needed on the benefits of job aids for screening and counseling.

A qualitative study to explore the attitudes of women and obstetricians towards caesarean delivery in rural Bangladesh

BackgroundCaesarean section is a lifesaving surgical intervention for women and their newborns, though overutilization is a public health concern. The caesarean rate in Bangladesh is approximately 23% overall, and in private facilities it is over 70%. It is essential to know both the supply side (obstetricians) and demand side (parturient women) views on caesarean birth in order to formulate specific interventions to address the escalating rate of caesareans.MethodsThis qualitative study took place in Matlab, a rural sub-district in Bangladesh. We interviewed women attending their 3rd antenatal visit, those with recent caesareans, and obstetricians from both public and private health facilities. In total there were twenty in-depth interviews and four focus group discussions. Study participants were asked about their preferences on birthing mode and knowledge of the caesarean section process. Thematic data analysis was done following a deductive approach.ResultsWomen from this rural community had a strong preference for normal vaginal birth. However, they were willing to accept the attending health care provider’s decision for caesarean birth. Antenatal care sessions did not provide information on the medical indications for caesarean section. Furthermore, some women had the misconception that episiotomy itself is a ‘small caesarean.’ Primary health care providers and clinic agents (brokers) had a strong influence on women’s decision to choose a health facility for giving birth. However, obstetricians, having a preference for caesarean section, were receiving more patients from these brokers which may be an important reason for the high rate of clinically non-indicated caesareans at private hospitals in Bangladesh. Improper labour monitoring and inadequate staffing at health facilities were additional influences on the preference for caesarean section. However, critical knowledge gaps were also observed among study obstetricians, particularly with regards to the indications for and timing of elective caesarean sections.ConclusionThere is a need to educate women about the advantages and disadvantages of different birthing modes to ensure their active participation in the decision making process. Strong policy regulations are needed to ensure legitimate decision making by obstetricians regarding mode of birthing.

O035 PHARMACY AND MEDICINE SELLERS' KNOWLEDGE AND PROVISION OF MISOPROSTOL FOR MENSTRUAL REGULATION IN BANGLADESH

Objectives: Due to their accessibility and relative anonymity, pharmacies are especially attractive to people seeking care for stigmatizing health issues, such as STIs, family planning and abortion or menstrual regulation (MR). MR is the evacuation of the uterus of a woman at risk of being pregnant to ensure a state of non-pregnancy and is sanctioned by the government of Bangladesh. Despite the lack of reliable data, anecdotal evidence suggests women may be using medications they obtain from medicine sellers and/or pharmacies to induce MR or abortion. The extent to which this practice is taking place in Bangladesh is unknown as is the extent to which medicine sellers are aware of the safe and effective regimens. We investigated the availability and provision knowledge and practices of misoprostol and other abortifacient drugs in pharmacies and medicine shops in Dhaka and Gazipur Districts. Methods: This 9 month cross-sectional study included 3 consecutive components: 1) mapping and listing of all pharmacies in the 2 study areas; 2) conducting a knowledge and practices survey among pharmacies randomly selected from the mapping list; and 3) simulated client visits using 4 different role-playing scenarios in all selected pharmacies. Results: Survey respondents (n = 331) had a mean age of 34 years; 73% had college education or higher and 28% had no formal training for selling medicine. Almost all had heard of MR. When asked about methods used for MR, 96% of respondents reported the use of pills, and 93% reported surgical methods; 65% knew the legal limit for MR. 98% of respondents reported that clients are asking them for methods for pregnancy termination. 20% of pharmacies did not recommend any drug for MR; 35% recommended misoprostol only and 36% recommended misoprostol with another drug. No respondent described using an effective regimen for MR. In the simulated client visits, 94% of the sellers did not provide or refer the client for post-MR family planning. Conclusions: There is growing concern about the ineffective provision of misoprostol for MR through pharmacies in Bangladesh. This study suggests that pharmacy provision of misoprostol for MR is common. It also shows that pharmacists are providing ineffective drugs and regimens for MR. These study findings suggest that targeted resources and training for medicine sellers are required to improve the quality of MR in Bangladesh.