Megan Swanson

Characteristics of women who undergo second-trimester abortion in the setting of a fetal anomaly ☆

BACKGROUND Most women diagnosed with a fetal anomaly terminate the pregnancy. Little is known about utilization of two procedures: dilation and evacuation (D&E) and induction termination. STUDY DESIGN This retrospective cohort study included all women seen at the University of California, San Francisco (UCSF) Prenatal Diagnosis Center (PDC) who underwent a second-trimester abortion for an anomalous pregnancy from 2005 to 2008. We abstracted variables from the PDC database and medical charts to identify predictors associated with undergoing D&E. RESULTS Three quarters of the 192 women underwent D&E (n=148). Higher maternal age, proximity to UCSF, earlier gestational age, singleton gestation and genetic anomaly were associated with undergoing D&E. In adjusted analysis, earlier gestational age and singleton gestation were associated with undergoing D&E. CONCLUSIONS The D&E procedure was more commonly utilized for terminating an anomalous pregnancy at UCSF than medical induction. Further inquiry is needed to explore how provider counseling influences the choice of D&E vs. induction.

Delayed pregnancy testing and second-trimester abortion: can public health interventions assist with earlier detection of unintended pregnancy?

BACKGROUND Delayed pregnancy testing has been associated with presentation for abortion in the second trimester. Little is known about acceptability of potential interventions to hasten pregnancy recognition. STUDY DESIGN A total of 592 women presenting for abortion at six clinics in the United States completed surveys on contraceptive use, risk behavior, timing of first pregnancy test and interest in interventions to speed pregnancy recognition and testing. RESULTS Forty-eight percent of women presenting for second-trimester abortion delayed testing until at least 8 weeks. In multivariate analysis, women who often spotted between periods had higher odds of delaying pregnancy testing [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.04-6.94]. Women who often missed periods had higher odds of second-trimester abortion (OR 2.1, 95% CI 1.34-3.13). The majority (64%) of women were not aware of a fertile time in the menstrual cycle; these women had higher odds of second-trimester abortion (OR 2.0, 95% CI 1.21-3.37). Ninety-four percent of women expressed interest in at least one potential intervention to help recognize pregnancy earlier. CONCLUSIONS While there was near-universal interest in earlier pregnancy recognition, no single proposed intervention or scenario was endorsed by the majority. Improving sexual health awareness is an important consideration in future efforts to expedite pregnancy testing. IMPLICATIONS We found near-universal interest in earlier pregnancy recognition, though no single proposed intervention or scenario garnered majority support. Based on our findings, the concept of improving sexual health awareness through education should be incorporated in the development of future strategies to hasten recognition of unintended pregnancy.

Rethinking the ASCO Resource-Stratified Cervical Cancer Screening Guidelines in the Context of Existing Health Infrastructure in Basic Settings

In line with the WHO’s recommendation, the new ASCO guidelines for basic settings recommend human papillomavirus (HPV) testing, where feasible, as the primary screening modality given its simple interpretation and high sensitivity for cervical intraepithelial neoplasia and effectiveness at preventing progression to invasive cancer. The guidelines further stipulate that ifHPV testing isnot available or feasible, visual inspection with acetic acid (VIA) is an acceptable alternative.

Evidence-based improvisation: Facing the challenges of cervical cancer care in Uganda

There is significant disparity in the prevalence of cervical cancer globally, with low- and middle-income countries (LMICs) shouldering a disproportionate share of disease incidence and an even greater proportion of morbidity and mortality. Available resources for diagnosis, treatment and palliation of cervical cancer are inversely related to per capita income. While prevention and screening remain public health priorities, given the large number of women affected by cervical cancer, expanding treatment capacity should be included in any evidence-based intervention plan. Uganda, a country with a high incidence of cervical cancer, serves as a representative case study in terms of the challenges of diagnosis and access to treatment in sub-Saharan Africa. Providers and patients in Uganda are challenged by late presentation to care, limited training opportunities, cost-prohibitive diagnostic studies, insufficient access to gold-standard treatment, and under-utilized palliative care services. This review highlights the ways in which Ugandas experience is typical of the continent at large, as well as areas where Uganda is unique. We describe the ways in which a small but dedicated group of gynecologists carefully use limited evidence and available resources creatively to provide the best possible care for their patients. We show that improvisation, albeit evidence-based, is central to the nature and success of oncology care in Africa (Livingston, 2012). We argue that a “recalibrated global response” (Farmer et al., 2010), particularly stressing the expansion of radiotherapy capabilities, could dramatically improve cancer care and outcomes for women in Uganda as well as in LMICs globally.

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study

BackgroundThe incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening.MethodsIn December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy.ResultsDoor-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone.ConclusionNearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge.Trial registrationNCT02124252, Registered 25 April 2014.