Nuriye Ortayli

Assessing the acceptability, service delivery requirements, and use-effectiveness of the diaphragm in Colombia, Philippines, and Turkey.

The diaphragm is not available in many countries, despite the recommendations of numerous authors that it has important advantages as a woman-controlled method that offers some protection against sexually transmitted diseases, and one that is safe and free of side effects. An interagency team collaborated to introduce the diaphragm in Colombia, the Philippines, and Turkey, using the same protocol to assess the acceptability, service delivery requirements and use-effectiveness of the method. Eighteen public and private sector service delivery sites were involved and a total of 550 women were enrolled in the study. Provider training aimed to improve the quality of care with which all methods were delivered and included counseling about sexuality and reproductive health risks. The cumulative 12-month pregnancy rate of 10.1 (SE 1.7) per 100 woman-years is on the low end of previous studies of the diaphragm, and the 12-month continuation rate (57.2 [SE 2.4] per 100) compares favorably with that for oral contraceptives and the intrauterine device. Focus group discussions conducted with clients and providers indicated that the method was an important alternative for some women, particularly those who had experienced health problems with other methods or were unable to negotiate condom use with their partners. Provider biases diminished as they observed the strategic niche that the diaphragm filled for their clients. While providing the diaphragm requires training and good client-provider interaction, the requirements are consistent with those called for in the Programme of Action of the International Conference on Population and Development (ICPD, 1994). With proper attention to quality of care, the diaphragm can be successfully offered in resource-poor settings.

Immediate postabortal contraception with the levonorgestrel intrauterine device, Norplant, and traditional methods.

Women seeking legal first trimester abortion were counseled concerning contraception methods available for use immediately postabortion. Fifty women each accepted hormonal methods that were available only in the clinic and were novel to the country, the levonorgestrel IUD and Norplant implants, whereas another 50 chose either coitus interruptus or abstinence. All were experienced contraceptors, but larger percentages of women selecting the levonorgestrel IUD or implants had used the pill or IUDs previously, were under age 30, and weighed less than 60 kg compared to the other study participants. In the initial 2-6 weeks postabortion, women using the long-acting hormonal methods resumed sexual activity earlier and experienced more bleeding and spotting days than did other study participants, but their hematocrits were not adversely affected. No clinically significant side effects were noted in any group in the 6 weeks following the abortion. At the end of 1 year of follow-up, women using the hormonal methods had experienced no pregnancies and had high rates of continuation. IUD and implant participants had greater weight gain than did the other participants, but their mean weight remained below that of participants using traditional methods. No significant between-group differences in levels or changes in levels from admission were noted in hematocrit and blood pressure. The women found the levonorgestrel implants and IUDs easy and safe to use and highly effective. Bleeding disturbances, including amenorrhea, were the principal features the women disliked.

Is the diaphragm a viable option for women in Turkey

Diaphragms were offered to women as a contraceptive option during counseling sessions at four family planning clinic sites in western Turkey: two public-sector clinics (one in Capa Istanbul; the other in Izmir) and two private-sector clinics (one in Incirli Istanbul; the other in Denizli). Women who chose the diaphragm were interviewed at enrollment and were invited for follow-up visits with a physician at 2 weeks and at any time thereafter. Demographic information was also collected from an additional 740 women who chose another contraceptive method and focus-group discussions were conducted with diaphragm users and their partners with users of other methods and with service providers. Overall 166 women selected the diaphragm and 161 enrolled in the study. Initial acceptance rates were higher at the two private clinics (14% and 6%) than at the two public clinics (3% and 1%). At the public-sector clinics diaphragm users were better educated and more likely to be professionally employed than were women who selected other contraceptive methods. In Capa 42% of women who chose the diaphragm were university graduates compared with 7% of those who chose another method. Despite differences between the two private clinics in clients educational levels no such differences existed between diaphragm acceptors and users of alternative methods at each site. Among women who chose the diaphragm 47% said they had sex four times or more per week compared with 29% of those using another contraceptive. More than half of the women who selected the diaphragm (59%) cited safety and freedom from side effects as the reason for their choice of contraceptive. A similar percentage of clients who used other methods (58%) cited effectiveness. 50% of diaphragm users had discontinued by 6 months and 66% had done so by 12 months. A small proportion of clients in both private- and public-sector clinics were interested in using the diaphragm and found it acceptable. In less-developed countries the diaphragm may be a viable contraceptive option when providers are able to provide adequate information and support. (authors)

Users' perspectives on implantable contraceptives for women.

Users of subdermal contraceptive implants report long duration of use, convenience, and high efficacy as liked features and bleeding irregularities, weight loss/gain, and headaches as disliked effects of these methods. Satisfied users tend to be women who do not experience side effects or women who value positive features and tolerate the side effects. Satisfaction of the users is also closely related to quality of services. Service delivery problems, such as lack of proper pre-insertion counseling, inadequacy in number and imbalance in the geographical distribution of providers who can insert and remove implants, and appropriately manage side effects have been observed in new programs. Insensitivity of some providers to side-effects, such as bleeding irregularities, and to requests for removal have caused user dissatisfaction and serious public concern. Care must be taken to provide implants in a context of high quality of care with adequate numbers and distribution of trained providers and a basic record-keeping and tracking system.

The effectiveness of preabortion contraception counseling

Objective: To demonstrate the impact of preabortion counseling followed by immediate postabortal provision of the chosen method on postabortion contraceptive use. Methods: Three hundred and forty‐two women undergoing voluntary termination of pregnancy at less than 10 weeks gestation were enrolled at the Woman and Child Health Training and Research Clinic, Medical School of Istanbul. Clinic visits and telephone surveys were performed to measure contraceptive use at 6 months following abortion. Result: Two hundred and thirty‐six women either visited the clinic or responded to the telephone survey. Eighty percent of the respondents reported use of a modern contraceptive as compared to less than 40% prevalence found in the national survey. Conclusion: Preabortion counseling combined with immediate postabortal provision of contraceptives may significantly increase contraceptive use at 6 months postprocedure.

Sexually transmitted infections: progress and challenges since the 1994 International Conference on Population and Development (ICPD)

BACKGROUND Despite being recognized as an important challenge at the 1994 International Conference on Population and Development (ICPD), sexually transmitted ınfections (STIs) other than HIV are one of the most neglected dimensions of sexual and reproductive health. STIs, often undiagnosed and untreated, have especially harmful consequences for women and their neonates. PROGRESS SINCE ICPD During the last two decades, substantial knowledge and experience have accumulated in behavior change programming during the global response to the HIV epidemic which can also be used for prevention of STIs. There has been progress in development and implementation of vaccines against certain STIs such as hepatitis B and the human papilloma virus. Development of a rapid, point-of-care test for syphilis has opened the door to control this infection. CHALLENGES The estimated annual incidence of non-HIV STIs has increased by nearly 50% during the period 1995-2008. The growth in STIs has been aggrevated by a combination of factors: lack of accurate, inexpensive diagnostic tests, particularly for chlamydia and gonorrhea; lack of investment to strengthen health systems that can deliver services for diagnosis and management of STIs; absence of surveillance and reporting systems in the majority of countries; political, socioeconomic and cultural barriers that limit recognition of STIs as an important public health problem; and failure to implement policies that are known to work. RECOMMENDATIONS Governments, donors and the international community should give higher priority to preventing STIs and HIV; fully implementing behavior change interventions that are known to work; ensuring access of young people to information and services; investing in development of inexpensive technologies for STI diagnosis,treatment and vaccines; and strengthening STI surveillance, including of microbial resistance.

Curable sexually transmitted infections among the clientele of a family planning clinic in Istanbul Turkey.

Background Integrating screening and treatment of sexually transmitted infections into existing family planning programs can be a good way to fight this problem. Also, the number of studies on the prevalence of certain sexually transmitted infections in this population in Turkey is limited. Goal To find out the prevalence of the most common sexually transmitted infections among the clients of an urban family planning clinic and to evaluate demographic characteristics and clinical signs related to sexually transmitted infections. Study Design Samples for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis were collected from 569 women who attended the clinic from December 15, 1997 to March 31, 1998. Results No case of N gonorrhoeae was found among the samples. The prevalence of C trachomatis infection was 1.9%, whereas the prevalence of of T vaginalis was 2.6%. None of the demographic characteristics or clinical signs was related to these infections. Conclusion Larger studies using more sensitive laboratory tests are needed to determine the prevalence of chlamydial infections in family planning clinics in Turkey.