Rachel Pope

Home or office etonogestrel implant insertion after pregnancy: a randomized trial.

OBJECTIVES To evaluate whether home visits for contraceptive implant insertion result in an increase in postpartum uptake compared to clinic insertion and to assess the feasibility of home insertions. STUDY DESIGN We randomized women within 10 weeks of a birth or dilation and curettage (D&C) for abortion or miscarriage to home or standard office insertion. The primary outcome was successful insertion of the implant. To achieve 80% power to detect a 40% difference in visit attendance, 20 women were assigned to each group. The secondary outcome was attendance of the 4-week postpartum visit. RESULTS From June 2013 through February 2014, we screened 45 women and 40 were randomly assigned to home and office insertion visits. We enrolled 37 postpartum women and 3 women post-D&C. Because of the significant under enrollment of the latter, we chose to report results of only the postpartum women. The results were similar whether we included or excluded post-abortion women. A majority of women desired a home visit for their implant insertion appointment at time of enrollment. Postpartum appointment attendance rates were similar between home and office visits at 53% and 50% (p=1.00), respectively. Home visits resulted in a trend toward increased implant uptake [12/19 (63%) vs 6/18 (33%), p=.10]. CONCLUSION Home insertion of the contraceptive implant may be a feasible option. Future studies that examine the feasibility and uptake in both postpartum and post-D&C women are warranted. IMPLICATIONS Women reported preference for home insertion visits in this pilot study. We also showed that a greater proportion of women received the etonogestrel implant at a home visit compared to the current standard of care, which may warrant larger studies that would have sufficient power to evaluate smaller differences.

The Use of Singapore Flaps for Vaginal Reconstruction in Women with Vaginal Stenosis with Obstetric Fistula: A Surgical Technique

Gynecologic and plastic surgeons collaborate to improve vaginal reconstruction for women with vaginal stenosis and obstetric fistula. As these cases occur typically in low‐resource settings, the Singapore flap is a useful technique given its reliability, safety, ease of dissection, and minimal need for additional supplies. The fasciocutaneous flap maintains cutaneous innervation and vasculature and does not require stenting. The surgical collaboration has made it possible to provide functional vaginal reconstruction as a part of the overall care of obstetric fistula patients. The technique shows promise for improving sexual function for women with obstetric fistula and may also enhance healing.

She did the right thing: the high price of poor access to obstetric care.

et al. Community-based situation analysis of maternal and neonatal care in South Africa to explore factors that impact utilization of maternal health services. J Midwifery Womens Health 2007;52:342–50. 49 Hailu M, Gebremariam A, Alemseged F, Deribe K. Birth preparedness and complication readiness among pregnant women in Southern Ethiopia. PLoS One 2011;6:e21432. 50 Moran AC, Sangli G, Dineen R, Rawlins B, Yameogo M, Baya B. Birth-preparedness for maternal health: findings from Koupela District, Burkina Faso. J Health Popul Nutr 2006;24:489–97. 51 Rosato M, Mwansambo CW, Kazembe PN, Phiri T, Soko QS, Lewycka S, et al. Women’s groups’ perceptions of maternal health issues in rural Malawi. Lancet 2006;368:1180–8. 52 Colbourn T, Nambiar B, Bondo A, Makwenda C, Tsetekani E, Makonda-Ridley A, et al. Effects of quality improvement in health facilities and community mobilization through women’s groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial. Int Health 2013;5:180–95. 53 Lewycka S, Mwansambo C, Rosato M, Kazembe P, Phiri T, Mganga A, et al. Effect of women’s groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial. Lancet 2013;381:1721–35. 54 Spangler SA, Bloom SS. Use of biomedical obstetric care in rural Tanzania: the role of social and material inequalities. Soc Sci Med 2010;71:760–8. 55 Hounton S, Menten J, Ouedraogo M, Dubourg D, Meda N, Ronsmans C, et al. Effects of a Skilled Care Initiative on pregnancy-related mortality in rural Burkina Faso. Tropical Med Int Health 2008;13 (Suppl 1):53–60. 56 Kayongo M, Rubardt M, Butera J, Abdullah M, Mboninyibuka D, Madili M. Making EmOC a reality – CARE’s experiences in areas of high maternal mortality in Africa. International Journal of Gynecology and Obstetrics 2006;92:308–19. 57 Tayler-Smith K, Zachariah R, Manzi M, Van den Boogaard W, Nyandwi G, Reid T, et al. An ambulance referral network improves access to emergency obstetric and neonatal care in a district of rural Burundi with high maternal mortality. Tropical Med Int Health 2013;18:993–1001. 58 Fournier P, Dumont A, Tourigny C, Dunkley G, Drame S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 2009;87:30–8.

The ethical and technical aspects of urinary diversions in low‐resource settings: a commentary

diversions in low-resource settings: a commentary J Wilkinson, R Pope, TJ Kammann, K Scarpato, TJIP Raassen, MC Bishop, M Morgan, MT Cartmell, E Chipungu, M Sion, M Weinstein, SJ Lengmang, H Mabeya, J Smith a Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA b Department of Urologic Surgery, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA c AMREF, Clinical Services, Nairobi, Kenya d Barley Coomb Barn, Salhouse, Norwich, UK e Department of Obstetrics and Gynecology, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, USA f Department of Surgery, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK g Freedom from Fistula Foundation, Fistula Care Center, Lilongwe, Malawi h Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA i Evangel Vesico Vaginal Fistula Center, Bingham University Teaching Hospital, Jos, Nigeria j Division of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya Correspondence: J Wilkinson, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main St., Houston, TX 77030, USA. Email jeffreypwilkinson@gmail.com

Barriers to Global Health Training in Obstetrics and Gynecology.

BACKGROUND The Lancet Commission on Global Surgery includes obstetrics and gynecology as an area needing international strengthening in low- and middle-income countries. Despite interest, a majority of participants in US residency programs graduate with little exposure to global health or preparation to work abroad. OBJECTIVE The aim of this study was to determine the level of interest of obstetrics and gynecology (Ob/Gyn) residents in gaining global health training and to identify perceived barriers to receiving training. METHODS Residents in accredited Ob/Gyn programs were identified using a national residency database. The survey was online and anonymous. FINDINGS A total of 278 residents completed the survey. A high level of motivation to participate in a global health elective was associated with interests in preparation for future global work, desire for activism in maternal health and social determinants of health, and becoming better informed on global health policy. Eighty-two percent of respondents stated they would participate in a global health curriculum if it were offered, and 54.8% would use their vacation time. There were associations between personal safety, family, lack of resources, and lack of interest from faculty and motivational level as perceived barriers. Eighty-one percent strongly agreed that scheduling conflicts and time constraints pose barriers; more than 80% either agreed or strongly agreed that funding such endeavors and a lack of mentorship are major deterrents to pursuing global health. CONCLUSIONS Because resident motivation is clearly high and international need persists, we determined that most barriers to training abroad are related to the structure and budget of residency programs.

Pelvic Ultrasound Findings in Women with Obstetric Fistula: A Cross-Sectional Study of Cases and Controls

Objective Obstetric fistula (OF) is a morbid condition caused by prolonged obstructed labor. Women with OF experience profound injury and have high rates of infertility and poor obstetric outcomes. We examined endovaginal ultrasound parameters in women with and without OF. Design/Setting/Sample/Methods This cross-sectional study enrolled women evaluated at the Fistula Care Centre in Lilongwe, Malawi. Eligibility criteria included age 18–45, prior pregnancy, and a uterus on ultrasound. Participants underwent endovaginal ultrasound with measurement of cervical dimensions. Comparisons were done using t-tests and Fishers exact test. Among women with OF, linear regression was used to assess whether fistula stage was associated with cervical length. Results We enrolled 98 cases and 12 controls. Women with OF had shorter cervical lengths (18.8 mm versus 27.3 mm, p < 0.01), as well as shorter anterior (7.0 mm versus 9.3 mm, p < 0.01) and posterior (9.5 mm versus 11.0 mm, p < 0.04) cervical stroma, compared to controls. Conclusion Women with OF have shorter cervical lengths and anterior and posterior cervical stroma, when compared to women without OF. This may offer a partial explanation for subfertility and poor obstetric outcomes in OF patients. Additional studies to clarify the role of ultrasound in OF patients and prediction of future fertility are warranted.

The gracilis muscle flap for irreparable, “impossible”, and recurrent obstetric fistulas

Women in low-resource settings develop obstetric fistulas due to obstructed labor leading to incontinence and stigmatization. Most injuries are reparable; however, approximately 5% are not [1]. Due to multiple attempted repairs, scarring, small capacity bladders, and short or absent urethras, the only option is urinary diversion, which is fraught with complexities in low-resource settings [2]. This article is protected by copyright. All rights reserved.

Standardization of Laparoscopic Operative Reporting: Improving Gynaecological Surgeon Communication

OBJECTIVE No standardization of quality of operative reporting currently exists, and this represents a missed opportunity for communication among health care providers. This study proposed a method to improve operative notes by structuring the findings by six anatomical zones of the pelvis. Objective I was to validate the method of documenting six zones of the pelvis by using intraoperative photography. Objective II was to compare this method with dictations from operative reports created before introducing this method. METHODS This retrospective cohort study evaluated pre- and post-intervention results of using six zones to guide operative reporting. Reports were collected from participating surgeons and were scored using a validated scoring tool. Each participant was taught to photograph six zones and use the zones in the operative report. Pre- and post-intervention cases were compared using generalized linear mixed models. RESULTS Scores of study participants using the zones were significantly higher than those without (P <0.0001). Surgeons showed an ability to improve their reporting. The detail illustrated in the cases was qualitatively richer, and the anatomy within the six zones was referenced more frequently. CONCLUSION Compared with reports without the technique, incorporating the six zones greatly enhances operative reporting and likely would improve communication among care providers. More reliable communication of intraoperative findings has the potential to enhance the value of laparoscopy greatly as a diagnostic tool across gynaecological subspecialties.