Sandra G. García

Accuracy of Self-Screening for Contraindications to Combined Oral Contraceptive Use

OBJECTIVE: To estimate how well a convenience sample of women from the general population could self-screen for contraindications to combined oral contraceptives using a medical checklist. METHODS: Women 18–49 years old (N=1,271) were recruited at two shopping malls and a flea market in El Paso, Texas, and asked first whether they thought birth control pills were medically safe for them. They then used a checklist to determine the presence of level 3 or 4 contraindications to combined oral contraceptives according to the World Health Organization Medical Eligibility Criteria. The women then were interviewed by a blinded nurse practitioner, who also measured blood pressure. RESULTS: The sensitivity of the unaided self-screen to detect true contraindications was 56.2% (95% confidence interval [CI] 51.7–60.6%), and specificity was 57.6% (95% CI 54.0–61.1%). The sensitivity of the checklist to detect true contraindications was 83.2% (95% CI 79.5–86.3%), and specificity was 88.8% (95% CI 86.3–90.9%). Using the checklist, 6.6% (95% CI 5.2–8.0%) of women incorrectly thought they were eligible for use when, in fact, they were contraindicated, largely because of unrecognized hypertension. Seven percent (95% CI 5.4–8.2%) of women incorrectly thought they were contraindicated when they truly were not, primarily because of misclassification of migraine headaches. In regression analysis, younger women, more educated women, and Spanish speakers were significantly more likely to correctly self-screen (P<.05). CONCLUSION: Self-screening for contraindications to oral contraceptives using a medical checklist is relatively accurate. Unaided screening is inaccurate and reflects common misperceptions about the safety of oral contraceptives. Over-the-counter provision of this method likely would be safe, especially for younger women and if independent blood pressure screening were encouraged. LEVEL OF EVIDENCE: II

Estimates of induced abortion in Mexico: what's changed between 1990 and 2006?

CONTEXT In Mexico, where abortion remains largely illegal and clandestine, reliable data on induced abortion and related morbidity are critical for informing policies and programs. The only available national estimate of abortion is for 1990, and demographic and socioeconomic changes since then have likely affected abortion incidence. METHODS This study used official statistics on women treated for abortion-related complications in public hospitals in 2006 and data from a survey of informed health professionals. Indirect estimation techniques were used to calculate national and regional abortion measures, which were compared with 1990 estimates. RESULTS In 2006, an estimated 150,000 women were treated for induced abortion complications in public-sector hospitals, and one in every 5.8 women having an induced abortion were estimated to have received such treatment. The estimated total number of induced abortions in 2006 was 875,000, and the abortion rate was 33 per 1,000 women aged 15-44. Between 1990 and 2006, the abortion rate increased by 33% (from a rate of 25). The severity of morbidity due to unsafe abortion declined (as seen in shorter hospital stays), but the annual rate of hospitalization did not-it was 5.4 per 1,000 women in 1990 and 5.7 in 2006. The abortion rate was similar to the national average in three regions (34-36), but substantially lower in one (25 in the South/East region). CONCLUSIONS Clandestine abortion continues to negatively affect womens health in Mexico. Recommended responses include broadening the legal criteria for abortion throughout Mexico, improving contraceptive and postabortion services, and expanding training in the provision of safe abortion, including medical abortion.

Policy implications of a national public opinion survey on abortion in Mexico.

Abstract In Mexico, recent political events have drawn increased public attention to the subject of abortion. In 2000, using a national probability sample, we surveyed 3,000 Mexicans aged 15—65 about their knowledge and opinions on abortion. Forty-five per cent knew that abortion was sometimes legal in their state, and 79% felt that abortion should be legal in some circumstances. A majority of participants believed that abortion should be legal when a woman’s life is at risk (82%), a woman’s health is in danger (76%), pregnancy results from rape (64%) or there is a risk of fetal impairment (53%). Far fewer respondents supported legal abortion when a woman is a minor (21%), for economic reasons (17%), when a woman is single (11%) or because of contraceptive failure (11%). In spite of the influence of the Church, most Mexican Catholics believed the Church and legislators’ personal religious beliefs should not factor into abortion legislation, and most supported provision of abortions in public health services in cases when abortion is legal. To improve safe, legal abortion access in Mexico, efforts should focus on increasing public knowledge of legal abortion, decreasing the Church’s political influence on abortion legislation, reducing the social stigma associated with sexuality and abortion, and training health care providers to offer safe, legal abortions. Résumé Au Mexique, de récents événements ont mis l’avortement au centre de l’attention publique. En 2000,àpartir d’un échantillon aléatoire national, nous avons interrogé 3000 Mexicains âgés de 15à65 ansàpropos de leurs connaissances et leurs opinions sur l’avortement. Ils étaient 45%àsavoir que l’avortement est parfois légal dans leur Átat et 79% pensaient qu’il devait l’Átre dans certaines circonstances. Une majorité de répondants estimaient que l’avortement doit Átre autorisé si la vie (82%) ou la santé (76%) de la femme est en danger, si la grossesse résulte d’un viol (64%) ou si le Fatus présente des anomalies physiques ou mentales (53%). Nettement moins de personnes approuvaient l’avortement légal pour une mineure (21%), pour des motifs financiers (17%), si la femme est célibataire (11%) ou en raison d’un échec de la contraception (11%). Malgré le pouvoir de l’Áglise, la plupart des catholiques jugeaient que l’Áglise et les convictions des législateurs ne devaient pas peser sur la législation, et la plupart approuvaient la pratique d’avortements par les services de santé publics dans les cas autorisés par la loi. Pour améliorer l’accèsàl’avortement légal et médicalisé au Mexique, il faut informer la population, diminuer l’influence politique de l’Áglise sur la législation relativeàl’avortement, atténuer la stigmatisation associéeàla sexualité etàl’avortement, et former les prestataires de soins de santéàproposer des avortements légaux et médicalisés. Resumen En México, los últimos sucesos poláticos originaron una atención amplia del público hacia el tema del aborto. En el 2000, mediante una muestra de probabilidad nacional, encuestamos a 3,000 mexicanos entre los 15 y 65 años acerca de sus conocimientos y opiniones sobre el aborto. El 45% sabáa que el aborto a veces es legal en su estado, y el 79% estimaba que el aborto debe ser legal en algunos casos. La mayoráa estimó que el aborto debe ser legal cuando la vida de la mujer está en riesgo (82%), la salud de la mujer está en peligro (76%), el embarazo es producto de una violación (64%) o el feto tiene defectos mentales o fásicos (53%). Un número mucho menor de respondedores apoyaron la interrupción legal del embarazo cuando la mujer es menor de edad (21%), por motivos económicos (17%), cuando la mujer es soltera (11%) o debido a falla anticonceptiva (11%). A pesar de la influencia de la Iglesia, la mayoráa de los mexicanos católicos estiman que la Iglesia y las creencias religiosas de los legisladores no deberáan incidir en la legislación sobre el aborto, y la mayoráa apoyó la prestación de servicios por la salud pública en casos en los que éste es legal. A fin de mejorar el acceso al aborto seguro y legal en México, los esfuerzos deben centrarse en crear mayor conciencia entre el público respecto al aborto legal, disminuir la influencia polática de la Iglesia sobre la legislación de aborto, reducir el estigma social asociado con la sexualidad y el aborto, y capacitar a los profesionales de la salud para que provean abortos seguros y legales.

Mexican physicians' knowledge and attitudes about the human papillomavirus and cervical cancer: a national survey.

Objective: To assess Mexican physicians’ knowledge about the human papillomavirus (HPV) and cervical cancer and their opinions and practices related to screening, managing, and counselling women on these topics. Methodology: In August 2002 we surveyed 1206 general practitioners (GPs) and obstetricians-gynaecologists (Ob-Gyns) working in a nationally representative sample of public and private facilities in urban Mexico. Eligible physicians completed a self administered questionnaire. We conducted a weighted analysis and used χ2 tests to compare GPs and Ob-Gyns on outcome variables. Results: 76% of recruited physicians responded to the survey. 43% of Ob-Gyns had performed a hysterectomy in the last year to treat a case of CIN I or II. With respect to HPV, while 80% of respondents identified the virus as the principal cause of cervical cancer, many lacked detailed knowledge about this association. Ob-Gyns were more likely than GPs to have heard about specific oncogenic strains of HPV (p<0.001). Nearly all respondents thought that women should be informed that HPV causes cervical cancer; nevertheless, physicians believed that positioning cervical cancer as a sexually transmitted infection (STI) could cause problems in partner relationships (60%), confusion (40%), and unnecessary anxiety among women (32%). Conclusions: Mexican physicians support patient education on the HPV-cervical cancer link. However, findings suggest the need to present clear messages to women (emphasising, for example, that only certain types of HPV are oncogenic), to consider the conflicts such information might create for couples, and to further educate physicians about this topic and about overall cervical cancer screening and treatment protocols.

Diagnostic accuracy of a point-of-care syphilis test when used among pregnant women in Bolivia

Objective: To evaluate the performance of a point-of-care (POC) syphilis test when used in urban Bolivian maternity hospitals. Methods: We tested 8892 pregnant women for syphilis using the Abbott Determine Syphilis TP rapid POC test and rapid plasma reagin (RPR) in the laboratory of four large urban maternity hospitals where national statistics reported a syphilis prevalence of at least 3%. Sera were stored and transferred to the national reference laboratory (INLASA) where RPR testing was repeated. When the reference laboratory staff observed a positive RPR result, a Treponema pallidum particle agglutination assay (TPPA) was performed to confirm these findings. We calculated test performance characteristics for the POC test and hospital RPR using RPR performed at the reference laboratory confirmed by TPPA as the reference standard. Participants received treatment during their initial visit based on the POC test results. Results: The sensitivity, specificity, negative predictive value and positive predictive values of the POC syphilis test were: 91.8% (95% confidence intervals 88.4% to 94.5%), 98.5% (98.2% to 98.8%), 71.0% (66.6% to 75.2%), and 99.7% (99.5% to 99.8%), respectively. The RPR values were 75.7% (70.8% to 80.2%), 99.0% (98.9% to 99.3%), 76.9% (72.0% to 81.3%), and 99.0% (98.8% to 99.2%), respectively. Conclusion: The Abbott Determine Syphilis TP test proved to be more sensitive than routine RPR and had comparable specificity. POC testing may be a simple way to expand syphilis screening to clinics with no laboratory facilities, improve case detection, and facilitate treatment delivery.

The Measure of Induced Abortion Levels in Mexico Using Random Response Technique

The authors used the random response technique (RRT) to measure frequency of induced abortion in Mexico, where its practice is illegal under most circumstances. They applied RRT to a national, multistage probabilistic sample of 1,792 women ages 15 to 55. The distribution of women who reported having had an induced abortion was analyzed by sociodemographic characteristics. Bivariate and multiple logistic regression analyses were performed to identify factors associated with having had an induced abortion. Overall prevalence of induced abortion was 16.3 percent. Three factors were associated with reported induced abortion: having grown up in the city (bivariate odd ratio [OR] 2.16, multiple logistic OR 2.24), having never given birth (bivariate OR 1.60, multiple logistic OR 2.06), and having had an unwanted pregnancy (bivariate OR 2.09, multiple logistic OR 2.81). RRT produced a better estimation of induced abortion compared with other methodologies. This technique works best with urban and educated women.

Analysis of the operational costs of using rapid syphilis tests for the detection of maternal syphilis in Bolivia and Mozambique.

Objective: The objective of this study was to compare the costs of antenatal syphilis screening with the rapid plasma reagin (RPR) test and the immunochromatographic strip (ICS) test in low-resource settings. Goal: The goal of this study was to assess the costs of introducing rapid syphilis tests to reduce maternal and congenital syphilis. Study Design: Cost data were collected from participating study hospitals and antenatal clinics during 4 field visits to the 2 countries in 2003 and 2004. Health utilization outcome data on the number of women screened and treated routinely during the demonstration projects were used with unit cost data to estimate the incremental costs and average cost per woman screened and treated for maternal syphilis. Results: In Mozambique, the average cost per woman screened was U.S.

Sífilis materna y congénita en cuatro provincias de Bolivia

0.91 and U.S.

Demonstrating public health at work: a demonstration project of congenital syphilis prevention efforts in Bolivia.

1.05 for the RPR and ICS tests, respectively. In Bolivia, the average cost of screening was U.S.

Maternal syphilis and intimate partner violence in Bolivia: a gender-based analysis of implications for partner notification and universal screening.

1.48 and U.S.