An unfinished agenda on adolescent health: Opportunities for interventions

The Millennium Development Goal era has resulted in improvements in maternal and child health worldwide. As more children are surviving past their fifth birthday, the population of adolescents is increasing. Adolescence is a time of significant developmental transition; adolescence sets the stage for adult health through risks taken and beneficial and detrimental habits that are formed and it is thus an optimal time to target health interventions. Beginning interventions in adolescence or even earlier in childhood maximizes the impact on the individual's health in adult life. Evidence suggests that interventions to promote sexual and reproductive health, physical activity and healthy lifestyle, mental health and wellbeing, safe and hazard-free environment, improving access to nutritious and healthy foods, and minimizing exposure to substance abuse can improve health outcomes in young adolescents. School-based delivery strategies appear to be the most highly evaluated for improving adolescent health; they have been used to deliver interventions such as sexual health, substance abuse prevention, and nutritional interventions. Use of social media and information technologies, cash transfers, social protection, and micro-finance initiatives are promising strategies; however, given the lack of rigorous evaluations, there is a need for further research. Additional research is also warranted to strengthen the evidence base by establishing causality, understanding the differential impacts of adolescent health in different contexts particularly in low- and middle-income countries. In addition, research and evaluation in the domain of adolescent health must focus on how to implement interventions effectively at-scale, sustain the impacts over time and ensure equitable outcomes.

Sleep, sleep disturbance, and fertility in women

Sleep and sleep disturbances are increasingly recognized as determinants of women's health and well-being, particularly in the context of the menstrual cycle, pregnancy, and menopause. At present, however, little is known about whether fertility is affected by sleep quantity and quality. That is, to what degree, and by what mechanisms, do sleep and/or its disturbances affect fertility? The purpose of this review is to synthesize what is known about sleep disturbances in relation to reproductive capacity. A model is provided, whereby stress, sleep dysregulation, and circadian misalignment are delineated for their potential relevance to infertility. Ultimately, if it is the case that sleep disturbance is associated with infertility, new avenues for clinical intervention may be possible.

Experiences from the field: maternal, reproductive and child health data collection in humanitarian and emergency situations

BACKGROUND

Humanitarian emergencies can disproportionately affect women of reproductive age, and children. Good data on reproductive maternal, newborn and child health (RMNCH) are vital to plan and deliver programmes to address RMNCH needs. There is currently a lack of information regarding the availability, use and applicability of data collection tools.

METHODS

Key informant interviews (KII) were conducted with participants with experience of data collection in humanitarian settings, identified from relevant publications. Data were analysed using the thematic framework approach.

RESULTS

All participants reported challenges, especially in the acute phase of an emergency and when there is insufficient security. Four common themes were identified: the importance of a mixed methods approach, language both with regard to development of data collection tools and data collection, the need to modify existing tools and build local capacity for data collection. Qualitative data collection was noted to be time consuming but considered to be important to understand the local context. Both those who have experienced trauma (including sexual violence) and data collectors require debriefing after documenting these experiences.

CONCLUSIONS

There were numerous challenges associated with data collection assessing the health status of, and services available, to women and children in humanitarian settings, and researchers should be well prepared.

The existing therapeutic interventions for orgasmic disorders: recommendations for culturally competent services, narrative review

BACKGROUND

In recent years, a growing number of interventions for treatment of female orgasmic problems (FODs) have emerged. Whereas orgasm is a extra biologically and learnable experience, there is a need for practitioners that to be able to select which therapy is the most appropriate to their context.

OBJECTIVE

In this critical literature review, we aimed to assess areas of controversy in the existing therapeutic interventions in FOD with taking into accounted the Iranian cultural models.

MATERIALS AND METHODS

For the present study, we conducted an extensive search of electronic databases using a comprehensive search strategy from 1970 till 2014. This strategy was using Google Scholar search, "pearl-growing" techniques and by hand-searching key guidelines, to identify distinct interventions to women's orgasmic problem therapy. We utilized various key combinations of words such as:" orgasm" OR "orgasmic "," female orgasmic dysfunction" OR Female anorgasmia OR Female Orgasmic Disorder ", orgasmic dysfunction AND treatment, "orgasm AND intervention". Selection criteria in order to be included in this review, studies were required to: 1 employ clinical-based interventions, 2 focus on FOD.

RESULTS

The majority of interventions (90%) related to non-pharmacological and other were about pharmacological interventions. Self-direct masturbation is suggested as the most privilege treatment in FOD. Reviewing all therapies indicates couple therapy, sexual skill training and sex therapy seem to be more appropriate to be applied in Iranian clinical settings.

CONCLUSION

Since many therapeutic interventions are introduced to inform sexually-related practices, it is important to select an intervention that will be culturally appropriate and sensitive to norms and values. Professionals working in the fields of health and sexuality need to be sensitive and apply culturally appropriate therapies for Iranian population. We further suggest community well defined protocols to screen, assessment and management of women' sexual problems such as FOD in the Iranian settings.

Vouchers for family planning and sexual and reproductive health services: a review of voucher programs involving Marie Stopes International among 11 Asian and African countries

OBJECTIVES

To evaluate provision of vouchers for family planning and sexual and reproductive health (SRH) services.

METHODS

A review was conducted to assess the effects of 24 voucher programs in Marie Stopes International programs across 11 countries in Asia and Africa between 2005 and the present. The outcome measures were uptake of services; service use among specific subgroups; user satisfaction with service quality; and efficiency of service delivery.

RESULTS

Twelve of the 24 programs covered family planning only, whereas the other 12 programs covered family planning and/or SRH. Service uptake increased following implementation, although voucher redemption rates varied by program (44.1%-92.4%). Most programs were successful in reaching subgroups, such as the poor and young (under 25years), although this outcome depended on the targeting approach. Most programs recorded high user satisfaction; however, the evidence regarding efficiency was mixed.

CONCLUSIONS

Vouchers increased uptake of services and, in some cases, improved service quality and reach to specific groups. Nevertheless, robust evaluation designs are required to measure efficiency.

Vitamin D and uterine leiomyoma among a sample of US women: Findings from NHANES, 2001-2006

Scientific understanding of the etiology of uterine leiomyomata (UL) remains incomplete, but recent investigations have suggested an association between low Vitamin D and UL risk. In this study, we conducted a cross-sectional analysis of Vitamin D exposure, measured using serum levels of 25(OH)D (a Vitamin D metabolite), and self-reported UL diagnosis among 3590 women aged 20-54 in the National Health and Nutrition Examination Survey (NHANES 2001-2006). Multivariate logistic regression models comparing each quartile of 25(OH)D to the lowest quartile indicated no relationship between 25(OH)D and odds of UL in the whole population (Ptrend=0.37), or in sensitivity analyses. However, a probabilistic analysis correcting outcome misclassification indicated that insufficient 25(OH)D was associated with UL in white (Odds ratio (OR) median estimate: 2.17; 2.5, 97.5 percentiles: (1.26, 23.47)), but not black women (OR median estimate: 1.70; 2.5, 97.5 percentiles: (0.89, 3.51)), suggesting misclassification may have driven some of the null findings.

Unplanned pregnancies and reproductive health among women with bipolar disorder

BACKGROUND

The aim of this study was to investigate reproductive health and level of planning of pregnancies among women with bipolar disorder (BDW).

METHODS

63 euthymic women, with bipolar disorder type I, II or not otherwise specified diagnosis, were included and were matched with a control group of 63 healthy women. Demographic and clinical data, structured reproductive health measures and planning level of pregnancies were obtained and compared between groups.

RESULTS

Lower level of planning of pregnancies and higher frequency of unplanned pregnancies were found among BDW. Women with bipolar disorder reported history of voluntary interruption of pregnancies more frequent than women from control group. Current reproductive health care showed no differences between groups.

LIMITATIONS

Data based on self-report of participants and retrospective nature of some collected measures may be affected by information bias. The pregnancy planning measure has not been validated in this population before. Demographic and clinical characteristics of the sample study limit generalization of these findings.

CONCLUSIONS

Adverse reproductive events, as unplanned pregnancies and elective interruption of pregnancies, may be more frequent among BDW. Clinician must be aware of the reproductive health during treatment of young BDW and take measures to improve better family planning access.

"Right tool," wrong "job": Manual vacuum aspiration, post-abortion care and transnational population politics in Senegal

The "rightness" of a technology for completing a particular task is negotiated by medical professionals, patients, state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain technologies may challenge the meaning of the "job" they are designed to accomplish. Manual vacuum aspiration (MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion, known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is legally prohibited. Although state health authorities have championed MVA as the "preferred" PAC technology, the primary donor for PAC, the United States Agency for International Development, does not support the purchase of abortifacient technologies. I conducted an ethnography of Senegal's PAC program between 2010 and 2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC. While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and digital curettage. Anxieties about MVA's capacity to induce abortion have constrained its integration into routine obstetric care. This capacity also raises questions about what the "job," PAC, represents in Senegalese hospitals. The prioritization of MVA's security over women's access to the preferred technology reinforces gendered inequalities in health care.

Study on Awareness of Preconception Care and Reproductive Health Behaviors in Pre-honeymooners

PURPOSE

The purpose of this study was 1) to examine levels of awareness on preconception care and pregnancy, and reproductive health promoting behavior among pre-honeymooners; and 2) to explore the relationship between awareness levels of preconception care and pregnancy, and reproductive health promoting behavior.

METHODS

This study was a correlation design with a total of 134 participants (67 couples of pre-honeymooners). Data were collected with questionnaire.

RESULTS

Mean score of self-perception of awareness of preconception care and pregnancy was 2.82 out of 4. Content awareness level was 6.83 out of 13, and reproductive health promoting behavior score was 3.02 out of 4, indicating low to mid-level. Women reported higher scores in all variables than those in men. Self-perception awareness and content awareness of care and pregnancy had a weak positive correlation (r=.18, p=.038). Reproductive health promoting behavior was positively related to self-perception awareness of care and pregnancy (r=.33, p<.001) and content awareness of care and pregnancy (r=.23, p=.008).

CONCLUSION

Based on this results, a variety of nursing intervention strategies may need to promote reproductive health behavior such as raising awareness of the preconception care and pregnancy.

The Integrated Gateway Model: a catalytic approach to behavior change

OBJECTIVES

To develop and test an Integrated Gateway Model of behaviors and factors leading to subsequent positive reproductive, maternal, and child health behaviors.

METHODS

A secondary analysis was conducted using previously published household survey data collected from men (n=5551; 2011) and women (n=16144; 2011) in Nigeria and women in Egypt (n=2240; 2004-2007). The number of health behaviors each potential gateway behavior predicted was assessed by multivariate regression, adjusting for potential confounders. The influence of gateway factors on gateway behaviors was tested via interaction terms. Gateway behaviors and factors were ranked by the number of health outcomes predicted, both separately and synergistically.

RESULTS

The key gateway behavior identified in both datasets was spousal communication about family planning, whereas the key gateway factor was exposure to family planning messages.

CONCLUSIONS

The model could facilitate innovative research and programming that in turn might promote cascades of positive behaviors in reproductive, maternal, and child health.

Validity of an FFQ assessing the vitamin D intake of young Serbian women living in a region without food fortification: the method of triads model

OBJECTIVE

The objective of the present study was to examine the external validity of an FFQ designed to estimate dietary vitamin D intake compared with a plasma biomarker and three repeated 24 h dietary recalls in women of reproductive age in Serbia, where there is no exposure to food fortified with vitamin D. The method of triads was applied.

DESIGN

In a cross-sectional study, 422 women completed the Women and Reproductive Health FFQ (WRH-FFQ) during the winter months. From a representative subgroup (n 44), three 24 h dietary recalls and anthropometric parameters were collected as well as a fasting blood sample for vitamin D biomarker analyses. Correlation coefficients were calculated between each of the dietary methods. Validity coefficients, as a correlation between the measured and estimated 'true' exposure, were calculated using the method of triads. Bland-Altman plots were also constructed.

SETTING

Three major universities in Serbia.

SUBJECTS

Healthy young women (n 422) aged 18-35 years.

RESULTS

The WRH-FFQ estimate of vitamin D intake for all participants was 4.0 (sd 3.3) µg/d and 3.1 (sd 2.3) µg/d for the subgroup. Bland-Altman plots for these intakes showed high agreement. Validity coefficients for the FFQ, 24 h recall and biomarker were ρ QI=0.847 (95% CI 0.564, 0.928), ρ RI=0.810 (95% CI 0.537, 0.997) and ρ BI=0.499 (95% CI 0.190, 0.840), while the correlation coefficients were 0.686, 0.422 and 0.404.

CONCLUSIONS

The FFQ applied in the present study is a valid tool for assessing dietary vitamin D intake in women living in Serbia, a region without mandatory vitamin D food fortification.

Abortion access and state variation in observed unintended pregnancy

OBJECTIVE

The state-level proportion of pregnancies that are unintended is an important social and public health indicator, and comparisons between states inform policy discussions. Unintended pregnancy is measured as a composite of abortions and unintended births, each of which is measured with error. We investigate whether between-state differences in abortion access and demand may bias comparisons between states' unintended pregnancy proportions when pregnancy intentions are misreported.

STUDY DESIGN

We algebraically specify the model currently used to estimate unintended pregnancy, extend it to include underreporting, and simulate the impact of underreporting on observed unintended pregnancy. Comparing the impact of underreporting across states, we identify levels of underreporting at which between-state comparisons are compromised.

RESULTS

We find that underreporting of unintended pregnancies could bias between-state comparisons when reporting of unintended pregnancies is less than 90-95%.

CONCLUSION

Current methods for estimating state-level unintended pregnancy proportions may underestimate unintended pregnancy to a greater degree in places with less abortion, and between-state comparisons may be biased. Estimates of state-level unintended pregnancy proportions would be more comparable if adjustment for completeness of retrospective underreporting were included in the estimation process.

IMPLICATIONS

Estimates of unintended pregnancy should be adjusted for nonsampling error and include variances based on sampling and nonsampling error in order to permit robust comparisons between states, between populations, and across time. More research on the fidelity of retrospective reporting of pregnancy intention would facilitate this endeavor.

[Development of reproductive health program and identification of effect for married women immigrants]

PURPOSE

This study was done to develop a reproductive health program to improve reproductive health of women immigrants.

METHODS

The participants in the study were 58 immigrant women who lived in Vietnam, China, Philippines, or Cambodia before marriage. They were assigned to the experiment group (n=29) or the control group (n=29). The reproductive health program for this study consisted of reproductive health education, health counseling, phone monitoring, and emotional support based on Cox (1982)'s Interaction Model of Client Health Behavior and was implemented for four weeks.

RESULTS

There were significant differences in reproductive health knowledge (t=9.78, p<.001), reproductive health attitude (t=6.59, p<.001), and reproductive health behavior (t=5.11, p<.001) within and between groups after the reproductive health program. But there were no significant differences in clinical indicators between the two groups.

CONCLUSION

The results of this study indicate the that reproductive health program for the women immigrants is effective in terms of reproductive health knowledge, reproductive health attitude and reproductive health behaviors. Therefore, nurses in public and private facilities, such as multicultural centers and public health centers in each community, should develop strategies to expand and provide reproductive health programs for women immigrants.

Evidence to incorporate inclusive reproductive health measures in guidelines for childhood and adolescent cancer survivors

OBJECTIVE

Female childhood cancer survivors are at an increased risk of reproductive health impairment. We compared reproductive health outcomes with the recommended standard in a cohort of childhood cancer survivors.

STUDY DESIGN AND PARTICIPANTS

A retrospective chart review of 222 female childhood cancer survivors aged 21 years or younger that presented to a tertiary referral center between 1997-2008 was initiated. The main outcome measures were the compliance with the American Society of Clinical Oncology guidelines for childhood cancer survivor management of reproductive health. In particular, we evaluated menstrual cycle regularity, fertility preservation counseling, and endocrine profile, as defined by follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) levels as surrogate markers for ovarian reserve. Secondary outcomes were to study the contribution of survivor clinics in enforcing these guidelines.

RESULTS

Of 136 patients older than 13 years at their last visit, 58 patients (43%) had FSH data available and none had AMH data. Patients were stratified into 3 groups according to FSH levels. Forty of 58 patients (69%) have normal ovarian reserve (FSH level < 10), 10 of 58 patients (17%) have decreased ovarian reserve (FSH levels 10-40), and 8 of 58 patients (14%) have premature menopause, defined as FSH > 40. Most patients with amenorrhea have elevated FSH levels indicating primary ovarian insufficiency, while 3 patients (2.2%) have low FSH levels consistent with hypothalamic amenorrhea. None of the patients were counseled on fertility preservation.

CONCLUSIONS

Reproductive health follow-up in children with cancer, including FSH and AMH measurement when indicated, should be established and strictly adhered.

Understanding the black box: a systematic review of the measurement of the community mobilization process in evaluations of interventions targeting sexual, reproductive, and maternal health

Community mobilization (CM) interventions are often used to improve sexual, reproductive, and maternal health (SRMH). This systematic review provides an overview of CM indicators used in evaluation and then focuses on the use of linking constructs-those measures of the process of CM between programmatic outputs and outcomes. We identified 108 English-language articles evaluating 86 CM interventions that target SRMH. Content analysis was used to code CM indicators into five categories: qualitative descriptions of CM; participation, diffusion and community action indicators that measure tangible, programmatic outputs; and linking constructs that capture the process of moving from participation to empowerment. Fifty-five (64.0%) interventions include a CM indicator. Diffusion indicators are most common (56.4%); linking constructs are least common (20.0%). We found 23 linking constructs used in evaluations of 11 interventions, with limited information on psychometric properties available. Three evaluations report positive relationships between linking constructs and condom use, one of which was significant in multivariate analysis. To better understand how CM leads to improved outcomes, we recommend increasing the measurement of linking constructs in evaluations of CM interventions. Research should focus on developing and validating new linking construct indicators and better disseminating existing measurement tools.

Residential proximity to major roads and obstetrical complications

Exposure to air pollution is linked with an increased risk of preterm births. To provide further evidence on this relationship, we evaluated the association between proximity to major roads--as an index for air pollution exposure--and various obstetrical complications. Data were extracted from a database maintained by the perinatal hospital in Shizuoka, Japan. We restricted the analysis to mothers with singleton pregnancies of more than 22 weeks of gestation from 1997 to 2012 (n=19,077). Using the geocoded residential information, each mother was assigned proximity to major roads. We then estimated multivariate adjusted odds ratios and their 95% confidence intervals (CIs) for the effects of proximity to major roads on various obstetrical complications (preeclampsia, gestational diabetes mellitus, placenta abruption, placenta previa, preterm premature rupture of membrane (pPROM), preterm labor, and preterm births). We found positive associations of proximity to major roads with preeclampsia and pPROM. Living within 200 m increased the odds of preeclampsia by 1.3 times (95% CI, 1.0-1.8) and pPROM by 1.6 times (95% CI, 1.1-2.2). Furthermore, living within 200 m increased the odds of preterm births by 1.4 fold (95% CI, 1.2-1.7). Exposure to traffic-related air pollution increased the risk of preeclampsia and pPROM in this study. We propose a mechanism responsible for the association between air pollution and preterm births.

Types of reproductive disorders in underweight and overweight young females and correlations of respective hormonal changes with BMI

BACKGROUND

Higher risks of reproductive problems have been found in underweight and overweight women with rapid weight gain or loss but evidence is inconsistent especially in relation to the effect of age of body weight changes.

OBJECTIVE

The aim of our study was to detect the peculiarities of menstrual function, prevalence of different types of reproductive disorders and correlations of respective hormonal changes with body mass index (BMI) in young female patients with thinness or obesity since childhood.

MATERIALS AND METHODS

In this prospective cross-sectional study 48 underweight and 55 overweight/obese young women with different reproductive problems underwent complete clinical and hormonal analyses. All 103 patients had weight problems since childhood.

RESULTS

Polycystic ovarian syndrome and metabolic syndrome was the most frequent in overweight and obese women, whilst non-classical congenital adrenal hyperplasia and ovarian dysfunction prevailed in underweight women (p˂0.001). No difference was determined according to the age of menarche (p=0.885) and types of menstrual disturbances (p=0.34) between the study groups. Hypogonadotropic hypogonadism was not found in young women who were lean since childhood. Follicle-stimulating hormone (FSH) (p=0.013) and sex hormone binging globulin (SHBG) (p˂0.001) levels were higher in women with low BMI, whilst free testosterone (FT) (p=0.019) and total testosterone (TT) (p=0.003) levels were higher in high BMI participants. BMI negatively correlated with FSH (p=0.009) and SHBG (p=0.001); and positively correlated with FT (p=0.001) and TT (p=0.002).

CONCLUSION

Peculiarities of menstrual function and hormonal changes in young women with thinness or obesity since childhood are related to the types of reproductive disorders and their childhood BMI.

An assessment of antenatal care among Syrian refugees in Lebanon

BACKGROUND

After more than three years of violence in Syria, Lebanon hosts over one million Syrian refugees creating significant public health concerns. Antenatal care delivery to tens of thousands of pregnant Syrian refugee women is critical to preventing maternal and fetal mortality but is not well characterized given the multiple factors obtaining health data in a displaced population. This study describes antenatal care access, the scope of existing antenatal care, and antenatal and family planning behaviors and practice among pregnant Syrian refugees in various living conditions and multiple geographic areas of Lebanon.

METHODS

A field-based survey was conducted between July and October 2013 in 14 main geographic sites of refugee concentration. The assessment evaluated antenatal services among a non-randomized sample of 420 self-identified pregnant Syrian refugee women that included demographics, gestational age, living accommodation, antenatal care coverage, antenatal care content, antenatal health behaviors, antenatal health literacy, and family planning perception and practices.

RESULTS

In total, 420 pregnant Syrian refugees living in Lebanon completed the survey. Of these, 82.9% (348) received some antenatal care. Of those with at least one antenatal visit, 222 (63.8%) received care attended by a skilled professional three or more times, 111 (31.9%) 1-2 times, and 15 (4.3%) had never received skilled antenatal care. We assessed antenatal care content defined by blood pressure measurement, and urine and blood sample analyses. Of those who had received any antenatal care, only 31.2% received all three interventions, 18.2% received two out of three, 32.1% received one out of three, and 18.5% received no interventions. Only (41.2%) had an adequate diet of vitamins, minerals, and folic acid. Access, content and health behaviors varied by gestational age, type of accommodation and location in Lebanon.

CONCLUSIONS

Standards of antenatal care are not being met for pregnant Syrian refugee women in Lebanon. This descriptive analysis of relative frequencies suggests reproductive health providers should focus attention on increasing antenatal care visits, particularly to third trimester and late gestational age patients and to those in less secure sheltering arrangements. With this approach they can improve care content by providing early testing and interventions per accepted guidelines designed to improve pregnancy outcomes.

Tracking humanitarian funding for reproductive health: a systematic analysis of health and protection proposals from 2002-2013

BACKGROUND

The Inter-agency Working Group on Reproductive Health in Crises conducted a ten-year global evaluation of reproductive health in humanitarian settings. This paper examines proposals for reproductive health activities under humanitarian health and protection funding mechanisms for 2002-2013, and the level at which these reproductive health proposals were funded.

METHODS

The study used English and French health and protection proposal data for 2002-2013, extracted from the Financial Tracking Service (FTS) database managed by the United Nations Office for the Coordination of Humanitarian Affairs. Every project was reviewed for relevance against pre-determined reproductive health definitions for 2002-2008. An in-depth analysis was additionally conducted for 2009-2013 through systematically reviewing proposals via a key word search and subsequently classifying them under designated reproductive health categories. Among the relevant reproductive health proposals, counts and proportions were calculated in Excel based on their reproductive health components, primarily by year. Contributions, requests, and unfunded requests were calculated based on the data provided by FTS.

RESULTS

Among the 11,347 health and protection proposals issued from 345 emergencies between 2002 and 2013, 3,912 were relevant to reproductive health (34.5%). The number of proposals containing reproductive health activities increased by an average of 21.9% per year, while the proportion of health and protection sector appeals containing reproductive health activities increased by an average of 10.1% per year. The total funding request over the 12 years amounted to $4.720 billion USD, of which $2.031 billion USD was received. Among reproductive health components for 2009-2013 proposals, maternal newborn health comprised the largest proportion (56.4%), followed by reproductive health-related gender-based violence (45.9%), HIV/sexually transmitted infections (37.5%), general reproductive health (26.2%), and lastly, family planning (14.9%).

CONCLUSION

Findings show that more agencies are responding to humanitarian appeals by proposing to implement reproductive health programs and receiving increased aid over the twelve year period. While such developments are welcome, project descriptions show comparatively limited attention and programming for family planning and abortion care in particular.

Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies

Background

Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan.

Methods

Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers.

Results

All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services.

Conclusion

Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.

Approaches for identifying germ cell mutagens: Report of the 2013 IWGT workshop on germ cell assays(☆)

This workshop reviewed the current science to inform and recommend the best evidence-based approaches on the use of germ cell genotoxicity tests. The workshop questions and key outcomes were as follows. (1) Do genotoxicity and mutagenicity assays in somatic cells predict germ cell effects? Limited data suggest that somatic cell tests detect most germ cell mutagens, but there are strong concerns that dictate caution in drawing conclusions. (2) Should germ cell tests be done, and when? If there is evidence that a chemical or its metabolite(s) will not reach target germ cells or gonadal tissue, it is not necessary to conduct germ cell tests, notwithstanding somatic outcomes. However, it was recommended that negative somatic cell mutagens with clear evidence for gonadal exposure and evidence of toxicity in germ cells could be considered for germ cell mutagenicity testing. For somatic mutagens that are known to reach the gonadal compartments and expose germ cells, the chemical could be assumed to be a germ cell mutagen without further testing. Nevertheless, germ cell mutagenicity testing would be needed for quantitative risk assessment. (3) What new assays should be implemented and how? There is an immediate need for research on the application of whole genome sequencing in heritable mutation analysis in humans and animals, and integration of germ cell assays with somatic cell genotoxicity tests. Focus should be on environmental exposures that can cause de novo mutations, particularly newly recognized types of genomic changes. Mutational events, which may occur by exposure of germ cells during embryonic development, should also be investigated. Finally, where there are indications of germ cell toxicity in repeat dose or reproductive toxicology tests, consideration should be given to leveraging those studies to inform of possible germ cell genotoxicity.

Twenty years after International Conference on Population and Development: where are we with adolescent sexual and reproductive health and rights?

The International Conference on Population and Development in Cairo in 1994 laid out a bold, clear, and comprehensive definition of reproductive health and called for nations to meet the educational and service needs of adolescents to enable them to deal in a positive and responsible way with their sexuality. In the context of the ongoing review of the International Conference on Population and Development Programme of Action and the considerations for a post-2015 development agenda, this article summarizes the findings of the articles presented in this volume and identifies key challenges and critical answers that need to be tackled in addressing adolescent sexual and reproductive health and rights. The key recommendations are to link the provision of sexuality education and sexual and reproductive health (SRH) services; build awareness, acceptance, and support for youth-friendly SRH education and services; address gender inequality in terms of beliefs, attitudes, and norms; and target the early adolescent period (10-14 years). The many knowledge gaps, however, point to the pressing need for further research on how to best design effective adolescent SRH intervention packages and how best to deliver them.

Ensuring youth's right to participation and promotion of youth leadership in the development of sexual and reproductive health policies and programs

The purpose of this article was to reflect on the concepts of adolescence and youth, summarize models and frameworks developed to conceptualize youth participation, and assess research that has attempted to evaluate the implementation and impact of youth participation in the field of sexual and reproductive health and rights (SRHR). We searched and critically reviewed relevant published reports and "gray literature" from the period 2000-2013. "Young people" are commonly defined as those between the ages of 10 and 24 years, but what it means to be a young person varies largely across cultures and depends on a range of socioeconomic factors. Several conceptual frameworks have been developed to better understand youth participation, and some frameworks are designed to monitor youth development programs that have youth participation as a key component. Although none of them are SRHR specific, they have the potential to be adapted and applied also for adolescents' SRHR programs. The most monitored and evaluated intervention type is peer education programs, but the effectiveness of the approach is questioned. There are few attempts to systematically evaluate youth participation, and clear indicators and better methodologies still need to be developed. More research and documentation as well as the adoption of innovative practices for involving youth in sexual and reproductive health programs are needed. Participation is a right and should not only be evaluated in terms of effectiveness and impact. Youth participation in program and policy development should still be a priority.

Unintended Pregnancy and Its Adverse Social and Economic Consequences on Health System: A Narrative Review Article

Unintended pregnancy is among the most troubling public health problems and a major reproductive health issue worldwide imposing appreciable socioeconomic burden on individuals and society. Governments generally plan to control growth of births (especially wanted births as well as orphans and illegitimate births) imposing extra burden on public funding of the governments which inevitably affects economic efficiency and leads to economic slowdown, too. The present narrative review focuses on socioeconomic impacts of unintended pregnancy from the health system perspective. Follow of Computerized searches of Academic, 53 scientific journals were found in various databases including PubMed, EMBASE, ISI, Iranian databases, IPPE, UNFPA (1985-2013). Original articles, review articles, published books about the purpose of the paper were used. During this search, 20 studies were found which met the inclusion criteria. Unintended pregnancy is one of the most critical challenges facing the public health system that imposes substantial financial and social costs on society. On the other hand, affecting fertility indicators, it causes reduced quality of life and workforce efficiency. Therefore lowering the incidence of intended pregnancies correlates with elevating economic growth, socio-economic development and promoting public health. Regarding recent policy changes in Iran on family planning programs and adopting a new approach in increasing population may place the country at a higher risk of increasing the rate of unintended pregnancy. Hence, all governmental plans and initiatives of public policy must be regulated intelligently and logically aiming to make saving in public spending and reduce healthcare cost inflation.

Alternative supplement for enhancement of reproductive health and metabolic profile among perimenopausal women: a novel role of Nigella sativa

OBJECTIVES

The aim of this open label crossover study was to investigate the effects of Nigella sativa on reproductive health and metabolic profile of perimenopausal women in Rawang, Malaysia.

MATERIALS AND METHODS

Sixty nine perimenopausal women aged 45 to 65 were allocated into the experimental group treated orally with 1600mg/day of encapsulated pure powdered N. sativa compared to control groups treated with placebo for 12 weeks. At the end of study, participants underwent washout period for fourteen days before being crossed over and continued for another cycle of treatment. Participants were abstained from taking any other drugs, herbal preparations or food supplements throughout the study. Body weight, height, waist circumference, blood pressure, biochemical parameters and hormonal levels were measured at baseline and at the end of experiment for both cycles. Face to face interview was carried out at baseline and every week to check for compliance, minimize dropouts and to record reproductive health and quality of life indicators using Greene climacteric and SF-36 instruments.

RESULTS

The treatment groups in both cycles showed significant improvement with reference to low density lipoprotein cholesterol and blood glucose (P<0.05). There were no significant differences between groups in total cholesterol, high density lipoprotein and triglyceride concentration. Treatment with N. sativa induced a significant reduction of prevalence and severity of menopausal symptomsas well as significant improvement in some components of quality of life (P<0.05).

CONCLUSION

These results suggested that treatment with N. sativa exert a therapeutic and protective effect by modifying weight gain, improving lipid profile and blood glucose as well as hormonal level which is believed to play an important role in the pathogenesis of metabolic syndrome during menopause.

Uptake of a women-only, sex-work-specific drop-in center and links with sexual and reproductive health care for sex workers

OBJECTIVE

To longitudinally examine female sex workers' (FSWs') uptake of a women-only, sex-work-specific drop-in service and its impact on their access to sexual and reproductive health (SRH) services.

METHODS

For the present longitudinal analysis, data were drawn from the AESHA (An Evaluation of Sex Workers' Health Access) study, a community-based, open, prospective cohort of FSWs from Vancouver, BC, Canada. Data obtained between January 2010 and February 2013 were analyzed. Participants are followed up on a semi-annual basis. Multivariable logistic regression using generalized estimating equations was used to identify correlates of service uptake.

RESULTS

Of 547 FSWs included in the present analysis, 330 (60.3%) utilized the services during the 3-year study period. Service use was independently associated with age (adjusted odds ratio [AOR] 1.04; 95% confidence interval [CI] 1.03-1.06), Aboriginal ancestry (AOR 2.18; 95% CI 1.61-2.95), injection drug use (AOR 1.67; 95% CI 1.29-2.17), exchange of sex for drugs (AOR 1.40; 95%CI 1.15-1.71), and accessing SRH services (AOR 1.65; 95% CI 1.35-2.02).

CONCLUSION

A sex-work-specific drop-in space for marginalized FSWs had high uptake. Women-centered and low-threshold drop-in services can effectively link marginalized women with SRH services.

A pilot study about female adolescent/young childhood cancer survivors' knowledge about reproductive health and their views about consultation with a fertility specialist

OBJECTIVE

Impaired fertility and reproductive health after cancer treatment is an important quality-of-life issue among female childhood cancer survivors (CCSs). This study aims to measure female CCSs' knowledge about their reproductive health and their exposure to and views about reproductive counseling (RC).

METHOD

This is a cross-sectional, web-survey study of female CCSs aged 18 to 45 years who were diagnosed with cancer before age 21 years and currently had no evidence of disease.

RESULTS

Fifty-six CCSs participated (response rate = 48%; mean current age = 26). Knowledge about reproductive health after cancer treatment was severely limited within this sample of highly educated survivors (91% educated beyond high school), who provided correct answers only 32% of the time. Only 9 and 5% of the women had pursued RC with a fertility specialist before and after cancer treatment, respectively. The majority thought they had not been provided enough information about reproductive health. White ethnicity (p < 0.001), higher annual income (p = 0.007), and higher education level (p = 0.02) were significantly associated with a positive opinion about RC.

SIGNIFICANCE OF RESULTS

A limited number of CCSs took advantage of RC in spite of their high interest in and limited knowledge about reproductive issues. Targeted referrals for RC may allow for improved decision making about reproductive options.

Examining negative effects of early life experiences on reproductive and sexual health among female sex workers in Tijuana, Mexico

OBJECTIVE

To explore experiences during childhood and adolescence that influenced reproductive and sexual health among women who had entered the sex industry in adolescence.

METHODS

A qualitative study was conducted using information provided by 25 female sex workers (FSWs) from Tijuana, Mexico, who reported entering the sex industry when younger than 18 years. In-depth, semi-structured interviews were conducted with all participants between January 31, 2011, and July 8, 2011.

RESULTS

Four interrelated themes that shaped health experiences-early sexual abuse, early illicit drug use, ongoing violence, and limited access to reproductive and sexual health care-were identified. Participants reporting these experiences were at risk of unintended teenaged pregnancy, spontaneous abortion or stillbirth, and untreated sexually transmitted infections.

CONCLUSION

Programs and policies that address social, structural, and individual vulnerabilities during adolescence and adulthood are required to promote reproductive and sexual health among FSWs in Tijuana, Mexico.

State-specific estimates of complete smoke-free home rules among postpartum women, 2010

BACKGROUND

Secondhand smoke exposure increases an infant's risk of morbidity and mortality. We provide state-specific estimates for and characterize postpartum women with complete smoke-free home rules.

METHODS

Data were analyzed from 26 states and New York City (n=37,698) from the 2010 Pregnancy Risk Assessment Monitoring System, a population-based survey of women who recently delivered live-born infants. We calculated state-specific estimates of complete rules and assessed associations between complete rules and selected characteristics.

RESULTS

Overall, 93.6% (95% CI: 93.1-94.1) of women with recent live births had complete smoke-free home rules (86.8% [West Virginia] to 98.6% [Utah]). Demographic groups with the lowest percentage of rules were women who smoked during pregnancy/postpartum (77.6%), were non-Hispanic Black (86.8%), never initiated breastfeeding (86.8%), < 20 years of age (87.1%), <$15,000 annual income (87.6%), < 12 years of education (88.6%), unmarried (88.6%), initiated prenatal care late/had no prenatal care (88.8%), had Medicaid coverage (89.7%), had an unintended pregnancy (90.3%), and enrolled in WIC (90.6%).

CONCLUSIONS

Prevalence of complete smoke-free home rules was high among women with recent live births; however, disparities exist by state and among certain sub-populations. Women, particularly smokers, should be educated during and after pregnancy about secondhand smoke and encouraged to maintain 100% smoke-free homes.

The project connect health systems intervention: linking sexually experienced youth to sexual and reproductive health care

PURPOSE

To evaluate a health systems intervention to increase adolescents' receipt of high-quality sexual and reproductive health care services.

METHODS

Quasi experimental design. Twelve high schools in a large public school district were matched into pairs. Within each pair, schools were assigned to condition so that no control school shared a geographic border with an intervention school. Five yearly surveys (T1, T2, …, T5) were administered from 2005 to 2009 (N = 29,823) to students in randomly selected classes in grades 9-12. Community-based providers of high-quality sexual and reproductive health care services were listed on a referral guide for use by school nurses to connect adolescents to care.

RESULTS

Statistically significant effects were found for intervention school females on three outcomes, relative to controls. Relative to T1, receipt of birth control in the past year was greater at T4 (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [CI], 1.09-3.15) and T5 (AOR = 2.22; 95% CI, 1.32-3.74). Increases in sexually transmitted disease testing and/or treatment in the past year were greater in T1-T3 (AOR = 1.78; 95% CI, 1.05-3.02), T1-T4 (AOR = 1.73; 95% CI, 1.01-2.97), T1-T5 (AOR = 1.97; 95% CI, 1.17-3.31), and T2-T5 (AOR = 1.76; 95% CI, 1.06-2.91). Increases in ever receiving an HIV test were greater in T1-T4 (AOR = 2.14; 95% CI, 1.08-4.26). Among males, no intervention effects were found.

CONCLUSIONS

A school-based structural intervention can improve female adolescents' receipt of services.

Seeds of prevention: the impact on health behaviors of young adolescent girls in Uttar Pradesh, India, a cluster randomized control trial

Of the world's 1.2 billion adolescents (10-19 years), India is home to the largest number globally, about 243 million. However not much is known about the health of young adolescent girls (11-14 years) in India who enter puberty with substantial nutritional and health deficits. Identifying early adolescence as a "gateway" moment, the Saloni pilot study is arandomized control trial (RCT) to improve nutrition, hygiene and reproductive health behaviors in 30 schools in rural Uttar Pradesh (UP), India. A prevention model that includes Sadharanikaran, an ancient Indian theory of communication, guided the development of the intervention. The Saloni strategy includes a 10 session in-school intervention based on compassion, self efficacy, emotional well being, peer and parental support, packaged in the form of short, easy-to-use instructional modules. A diary designed to engage adolescent girls is provided to each girl. The cluster RCT was conducted from January 2010 to October 2011 with adolescent girls (11-14 years of age) in Hardoi district. The trial is a two-level, nested RCT with the unit of randomization being the block with 15 schools in the intervention arm and 15 schools in the control arm. A sample of 1200 girls was randomly selected. The intervention had a significant impact on more than 13 preventive health behaviors. About 65 percent girls in the intervention group had adopted 13 or more health behaviors at end line compared 4.5 percent in the control group at end line and 5 percent at baseline. Behavioral impact was demonstrated in all three areas of nutrition, hygiene and reproductive health. The study provides evidence that early adolescence is indeed a "gateway moment" to build nutritional and health reserves.

Finding the Twitter users who stood with Wendy

OBJECTIVE

I examine Twitter discussion regarding the Texas omnibus abortion restriction bill before, during and after Wendy Davis' filibuster in summer 2013. This critical moment precipitated wide public discussion of abortion. Digital records allow me to characterize the spatial distribution of participants in Texas and the United States and estimate the proportion of participants who were Texans.

STUDY DESIGN

Building a dataset based on all hashtags associated with the bill between June 19th and July 14th, 2013, I use GPS locations and text descriptions of locations to classify users by county of residence. Mapping tweets from accounts within the continental United States by day, I describe the residential composition of the conversation in total and over time. Using indirect estimation, I compute an estimate of the number of Texans who participated.

RESULTS

About 1.66 million tweets were sent using hashtags associated with the bill from 399,081 user accounts. I estimate counties of residence for 160,954 participants (40.3%). An estimated 115,500 participants (29%) were Texans, and Texans sent an estimated 48.8% of all tweets. Tweets were sent from users estimated to live in every region of Texas, including 189 of Texas' 254 counties. Texans tweeted more than non-Texans on every day except the filibuster and the day after.

CONCLUSION

The analysis measures real-life responses to proposed abortion restrictions from people across Texas and the United States. It demonstrates that Twitter users from across Texas counties opposed HB2 by describing the geographical range of US and Texan abortion rights supporters on Twitter.

IMPLICATIONS

The Twitter discussion surrounding Wendy Davis' filibuster revealed a geographically diverse population of individuals who strongly oppose abortion restrictions. Texans from across the state were among those who actively voiced opposition. Identifying rights supporters through online behavior may present a new way of classifying individuals' orientations regarding abortion rights.

Legal and ethical standards for protecting women's human rights and the practice of conscientious objection in reproductive healthcare settings

The practice of conscientious objection by healthcare workers is growing across the globe. It is most common in reproductive healthcare settings because of the religious or moral values placed on beliefs as to when life begins. It is often invoked in the context of abortion and contraceptive services, including the provision of information related to such services. Few states adequately regulate the practice, leading to denial of access to lawful reproductive healthcare services and violations of fundamental human rights. International ethical, health, and human rights standards have recently attempted to address these challenges by harmonizing the practice of conscientious objection with women's right to sexual and reproductive health services. FIGO ethical standards have had an important role in influencing human rights development in this area. They consider regulation of the unfettered use of conscientious objection essential to the realization of sexual and reproductive rights. Under international human rights law, states have a positive obligation to act in this regard. While ethical and human rights standards regarding this issue are growing, they do not yet exhaustively cover all the situations in which women's health and human rights are in jeopardy because of the practice. The present article sets forth existing ethical and human rights standards on the issue and illustrates the need for further development and clarity on balancing these rights and interests.

Sexual and reproductive health and HIV in border districts affected by migration and poverty in Tanzania

OBJECTIVES

To assess HIV knowledge, attitudes, sexual practices and sexual and reproductive health (SRH) service delivery in border areas of Tanzania, with a view to support the prioritisation of SRH interventions in border areas.

METHODS

The target sample comprised randomly selected people living near the border, aged 15 to 49 years. To gather information, we utilised: (i) a standardised questionnaire (n = 86; 42 men and 44 women) previously used in national household surveys conducted by the Tanzanian government; (ii) focus group discussions (ten male groups, n = 47; ten female groups, n = 51); and (iii) semi-structured interviews with service providers (n = 37).

RESULTS

The mean number of sexual partners, frequency of multiple concurrent partnerships and engagement in transactional sex were significantly higher in the border community than in the national population. Knowledge about HIV was comparable with that in the general population. Access to SRH services was limited in the border areas.

CONCLUSION

Efforts to reduce HIV transmission and to improve SRH in the border areas should focus on gaps in service delivery rather than education and information activities alone. In addition, multi-sectorial efforts spanning the health, social, legal and private sectors addressing gender imbalances and poverty alleviation are imperative for reducing poverty-driven unsafe transactional sex.

The impact of signing a memorandum of understanding on reproductive health with the Ministry of Public Health in Cameroon

Health statistics relating to Millennium Development Goals 4 and 5 are poor for most low-resource countries. Professional societies can assist governments to improve these health indicators. For an effective collaboration, the Society of Gynaecologists and Obstetricians Cameroon (SOGOC) and the Ministry of Public Health signed a memorandum of understanding on reproductive health. A major consequence of this collaboration was the ease of transfer of competence associated with SOGOC adopting a monitoring and evaluation role, which has improved quality of care. The impact of this collaboration for the Society has been significant; SOGOC is recognized as a partner and has an opportunity to play a leadership role in issues concerning reproductive health.

Slaughtering sacred cows: six institutional obstacles to advances in family planning

In order to capitalise on new opportunities to advance contraceptive and reproductive health choices globally, organisations working in these fields will need to overcome six institutional obstacles. These are: (i) committee management; (ii) over-medicalisation; (iii) fear of risk and controversy; (iv) conferences, meetings, and symposia; (v) obsession with coordination; and (vi) fear of sex. The reproductive health community will require energy, innovative approaches, and a sharp focus on service delivery to address these hurdles that will otherwise slow down and misdirect programmatic momentum.

Obstetrician-gynecologists' beliefs on the importance of pelvic examinations in assessing hormonal contraception eligibility

OBJECTIVE

To describe obstetrician-gynecologists' beliefs regarding the importance of pelvic examination (including external genitalia inspection, speculum examination, bimanual examination) in assessing hormonal contraception eligibility.

METHODS

In a national probability survey, 1020 obstetrician-gynecologists drawn from the American Medical Association's Physician Masterfile rated importance of the examination in four categories: very, moderately, a little and not important.

RESULTS

The response rate was 62% (n=521). Seventy-nine percent considered at least one exam component to be of some importance (very, moderately, or a little importance). Bimanual examination was rated more often than external examination in each level of importance (p<.001). Physicians who believed no component of the examination was important were more likely to be younger, female and in practice settings other than private practice.

CONCLUSIONS

Despite guidelines stating that pelvic examinations are unnecessary in assessing hormonal contraception eligibility, most obstetrician-gynecologists believe that they are of some importance. These attitudes may pose a barrier to contraception provision.

Access to transport for women with hypovolemic shock differs according to weeks of pregnancy

OBJECTIVE

To examine whether women with hypovolemic shock secondary to obstetric hemorrhage are transported to referral hospitals differently depending on weeks of pregnancy in Zambia.

METHODS

In a retrospective study, transport type, wait time, and transit time were assessed for women with obstetric hemorrhage and hypovolemic shock transported from 26 primary health centers to three referral hospitals during 2007-2012. A mean arterial pressure of less than 60 mm Hg was used to indicate severe shock. Women were split into two categories on the basis of the number of weeks of pregnancy (<24 weeks vs ≥24 weeks).

RESULTS

Overall, 616 women were included. Mode of transport differed significantly by group (P<0.001). 414 (93.0%) of 445 women at 24 weeks of pregnancy or more were transported by ambulance versus 114 (66.7%) of 171 women at less than 24 weeks. Among those in severe shock, 106 (93.0%) of 114 women at 24 weeks of pregnancy or more were transported in ambulances versus 26 (52.0%) of 50 women at less than 24 weeks (P<0.001).

CONCLUSION

Women at 24 weeks of pregnancy or more were given preference for ambulance transport even when signs of shock were equivalent. Policy-makers aiming to lower maternal mortality need to address transport issues regardless of the etiology of hemorrhage or week of pregnancy.

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.

Factors associated with utilization of reproductive healthcare services among migrant women workers in Chong Qing, China

OBJECTIVE

To investigate the use of reproductive healthcare services among migrant women workers in Chong Qing, China, and provide suggestions to improve the utilization of these services by young women.

METHODS

In a qualitative interview-based study between March, 2013 and June, 2013, personal in-depth interviews were conducted among young women workers, factory doctors, healthcare service providers, and policy-makers in Chong Qing, China.

RESULTS

Women workers seldom visited hospitals and did so only when their pain became unbearable. The workers' use of reproductive healthcare services was particularly influenced by the high cost of hospitalization and long waiting periods. Factory doctors could only solve minor problems. Public healthcare providers stated that migrant women had a higher morbidity rate from reproductive tract infections as compared with local women. The policy-makers considered that the health system was beneficial to women's reproductive health; however, few workers had good comprehension of government policies.

CONCLUSION

Migrant women workers are vulnerable owing to lack of reproductive health care. The government and both social and health enterprise should consider the convenience of these women and the affordability of treatments when formulating reproductive healthcare policies. Effective measures should be taken to improve the use of these services by migrant women workers.

A comparison of trends in cesarean delivery in Paraguay between 1995 and 2008

OBJECTIVE

To identify maternal factors associated with the rise in the cesarean delivery rate in Paraguay.

METHODS

Retrospective analysis of the 1995 and the 2008 National Survey on Demographic and Sexual and Reproductive Health data using multivariable logistic regression.

RESULTS

In 2008, 1094 (37.3%) deliveries were cesarean compared with 781 (19.3%) in 1995. Home births had decreased by 72.9%, accounting for 33.3% of the change in the proportion of cesarean deliveries. Private facilities were associated with an increased odds ratio of cesarean delivery of 2.60 (95% confidence interval [CI], 2.02-3.34) and 4.89 (95% CI, 3.67-6.51) in 1995 and 2008, respectively, and accounted for 32.8% of the increase in cesarean deliveries between 1995 and 2008. Cesarean delivery was also associated with a prior cesarean, insurance status, and maternal higher educational and economic status.

CONCLUSION

Between 1995 and 2008 the cesarean delivery rate in Paraguay almost doubled. More than one-third of deliveries were cesarean. Shifts toward facility- (particularly private) based deliveries and repeat cesarean for women with a previous cesarean influenced this increase. Practice guidelines, regulation, and oversight of facilities, along with education and information for pregnant women, are needed to curb unnecessary and potentially harmful surgical delivery interventions.

Female autonomy and reported abortion-seeking in Ghana, West Africa

OBJECTIVE

To investigate factors associated with self-reported pregnancy termination in Ghana and thereby appreciate the correlates of abortion-seeking in order to understand safe abortion care provision.

METHODS

In a retrospective study, data from the Ghana 2008 Demographic and Health Survey were used to investigate factors associated with self-reported pregnancy termination. Variables on an individual and household level were examined by both bivariate analyses and multivariate logistic regression. A five-point autonomy scale was created to explore the role of female autonomy in reported abortion-seeking behavior.

RESULTS

Among 4916 women included in the survey, 791 (16.1%) reported having an abortion. Factors associated with abortion-seeking included being older, having attended school, and living in an urban versus a rural area. When entered into a logistic regression model with demographic control variables, every step up the autonomy scale (i.e. increasing autonomy) was associated with a 14.0% increased likelihood of reporting the termination of a pregnancy (P < 0.05).

CONCLUSION

Although health system barriers might play a role in preventing women from seeking safe abortion services, autonomy on an individual level is also important and needs to be addressed if women are to be empowered to seek safe abortion services.

A mixed-methods exploration of the contraceptive experiences of female teens with epilepsy

PURPOSE

We explored the contraceptive experiences of female teens with epilepsy, including their knowledge and perceptions of interactions between antiepileptic drugs and hormonal contraception and contraceptive decision-making processes.

METHOD

From November 2012 to May 2013, we conducted one online survey (n=114) and 12 online focus group discussions (n=26) with female teens with epilepsy about their contraceptive experiences and unmet needs. Survey data were analyzed using descriptive statistics and focus group transcripts were analyzed thematically using modified grounded theory methods.

RESULTS

Both survey and focus group participants reported believing that interactions between epilepsy medications and hormonal contraceptives could lead to reductions in contraceptive efficacy and seizure control. However, their knowledge about these types of medication interactions was often incomplete. Many study participants viewed contraceptive decision making as a difficult process, and some participants reported avoiding hormonal contraceptives because of potential interactions with antiepileptic drugs. Study participants reported relying on health care providers and parents for contraceptive decision-making support. Focus group participants also reported they wanted health care providers to provide more in-depth and comprehensive counseling about contraception, and that they desired peer support with contraceptive decisions.

CONCLUSION

The ability to make informed contraceptive decisions is important for teens with epilepsy as interactions between anti-epileptic drugs and hormonal contraceptives can impact seizure occurrence and lead to an increased risk of unplanned pregnancy. Guidance for providers offering contraceptive care to this population is needed, as well as a contraceptive support tool that empowers teens with epilepsy to advocate for desired health care.

U.S. clinicians' perspectives on less frequent routine gynecologic examinations

OBJECTIVE

With newer recommendations for less frequent cervical cancer screening, longer intervals between routine gynecologic examinations might also be considered.

METHODS

A nationally representative mailed survey of U.S. obstetrician-gynecologists (n=521, response rate 62%) was conducted in 2010-11. Clinicians were asked their views on annual gynecologic examinations and on the consequences of extending the interval from annually to every 3 years for asymptomatic patients.

RESULTS

Over two-thirds considered annual gynecologic examination very important for women in their reproductive years (69%); fewer consider it very important for women in menopause (55%). Most anticipated that shifting examinations to every 3 years would result in lower patient satisfaction (78%), contraceptive provision (74%), and patient health and well-being (74%). Decreases in clinic volume (93%) and financial reimbursement (78%) were also expected. Anticipated effects of longer intervals varied by provider characteristics, geography, and practice setting.

CONCLUSION

Obstetrician-gynecologists in the U.S. believed that longer intervals between routine examinations would have negative repercussions for patients and medical practice, but there were differences by region, practice, and personal characteristics. Redefining annual gynecologic visits as contraceptive counseling and health maintenance visits could address financial and patient volume concerns, and perspectives from patients and other providers might reveal possible benefits of less frequent gynecologic examinations.

Cryptorchidism --disease or symptom?

Testes descend to the scrotum normally before birth. When they fail to do so, the boy is cryptorchid and has an increased risk for testicular germ cell cancer and subfertility later in life. Early correction of maldescent by orchiopexy operation improves the spermatogenetic capacity of the testis but does not return the testicular cancer risk to the control level. Testicular descent is regulated by testis-derived hormones testosterone and insulin-like peptide 3. Cryptorchidism can therefore be considered a symptom of impaired testicular function that may also be linked to other testicular diseases, such as germ cell cancer and subfertility. Early orchiopexy can alleviate the effects of cryptorchidism on spermatogenesis, but alertness for testicular cancer should be maintained. In searching the genetic and environmental reasons for these diseases, it is useful to consider their connection with each other.

Cadmium and Reproductive Health in Women: A Systematic Review of the Epidemiologic Evidence

An evolving body of evidence supports that cadmium, a non-essential heavy metal, may be associated with multiple adverse women's reproductive health outcomes. Our objective was to conduct a systematic review of epidemiologic studies that evaluated cadmium exposure and the following reproductive health outcomes: puberty/menarche, fertility, time to pregnancy, pregnancy loss, preeclampsia, endometriosis, uterine leiomyoma, and menopause. Twenty-two studies were identified based upon our search criteria. Available evidence was inadequate to draw meaningful conclusions for most of the reproductive outcomes studied. The strongest evidence was for a possible association between cadmium and preeclampsia, which was limited to cross-sectional studies. Some evidence, although conflicting, was also observed for fertility related outcomes. This lack of evidence underscores the need for additional research on cadmium and women's reproductive health outcomes.

Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam

OBJECTIVE

To determine predictors of repeat abortion in 3 provinces in Vietnam.

METHODS

In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥2) abortions.

RESULTS

Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P < 0.05).

CONCLUSION

Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion.

Dual use of condoms with other contraceptive methods among adolescents and young women in the United States

PURPOSE

To estimate the prevalence of and factors associated with dual method use (i.e., condom with hormonal contraception or an intrauterine device) among adolescents and young women in the United States.

METHODS

We used 2006-2010 National Survey of Family Growth data from 2,093 unmarried females aged 15-24 years and at risk for unintended pregnancy. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to assess the associations between dual method use at last sex and sociodemographic, behavioral, reproductive history, and sexual behavior factors.

RESULTS

At last sex, 20.7% of adolescents and young women used dual methods, 34.4% used condoms alone, 29.1% used hormonal contraception or an intrauterine device alone, and 15.8% used another method or no method. Factors associated with decreased odds of dual method use versus dual method nonuse included having a previous pregnancy (aOR = .44, 95% CI .27-.69), not having health insurance coverage over the past 12 months (aOR = .41, 95% CI .19-.91), and having sex prior to age 16 (aOR = .49, 95% CI .30-.78).

CONCLUSIONS

The prevalence of dual method use is low among adolescents and young women. Adolescents and young women who may have a higher risk of pregnancy and sexually transmitted infections (e.g., those with a previous pregnancy) were less likely to use dual methods at last sex. Interventions are needed to increase the correct and consistent use of dual methods among adolescents and young women who may be at greater risk for unintended pregnancy and sexually transmitted infections.

Sexual orientation and sexual and reproductive health among adolescent young women in the United States

PURPOSE

We studied sexual and reproductive health among self-identified bisexual, lesbian, and heterosexual adolescent young women. Prior research has suggested that bisexual and lesbian young women may be at greater risk for many negative health outcomes, including risky sexual and reproductive health behavior.

METHODS

Using data from the U.S. nationally representative 2006-2010 National Survey of Family Growth (NSFG), we examined sexual and reproductive health among young women 15-20 years of age as a function of sexual orientation. We used logistic regression and ANCOVA to examine differences in sexual and reproductive health across groups while controlling for demographic group differences.

RESULTS

Bisexual and lesbian young women reported elevated sexual and reproductive health risks. Bisexual and lesbian participants reported being younger at heterosexual sexual debut, and having more male and female sexual partners, than did heterosexual participants. Further, they were more likely than heterosexual young women to report having been forced to have sex by a male partner. Bisexual young women reported the earliest sexual debut, highest numbers of male partners, greatest use of emergency contraception, and highest frequency of pregnancy termination.

CONCLUSIONS

Overall, sexual minority young women-especially those who identified as bisexual-were at higher sexual and reproductive risk than their heterosexual peers.