Effectiveness of the lactational amenorrhea method in Pakistan

OBJECTIVE

To determine the efficacy of the lactational amenorrhea method of family planning (amenorrhea during full or nearly full breastfeeding for 6 months postpartum).

DESIGN

Prospective noncomparative study.

SETTING

Normal breastfeeding women in Karachi and Multan, Pakistan, most delivered at home by a midwife.

PATIENTS

Three hundred ninety-nine newly delivered mothers who successfully had breastfed a previous child and chose the lactational amenorrhea method to prevent a subsequent pregnancy, 391 of whom were followed for a full year.

INTERVENTIONS

Mothers were taught, before or shortly after delivery, to use the method and were interviewed in their homes each month by a Lady Health Visitor.

MAIN OUTCOME MEASURE

Life-table pregnancy rates. Periods of postpartum or lactational abstinence were excluded in the calculation of the pregnancy rates.

RESULTS

During full or nearly full breastfeeding, while the women were amenorrheic and not otherwise contracepting, the rate of pregnancy was 0.6%. The pregnancy rate during lactational amenorrhea alone was 1.1% at 1 year postpartum.

CONCLUSION

The lactational amenorrhea method was found to be highly effective for 6 months. A high degree of contraceptive protection endures for a full year during lactational amenorrhea, but not after the return of menses during breastfeeding.

[Damage to condoms caused by vaginally administered drug]

A 28-year-old woman who was treated for vaginal candidiasis with Gyno-Daktarin vaginal capsules (miconazole nitrate) became pregnant because a condom used during intercourse had ruptured. Incubation in vitro with 400 and 1200 mg miconazole nitrate vaginal capsules (Gyno-Daktarin 3 and Gyno-Daktarin I), but not miconazole nitrate vaginal cream (20 mg/g), was shown to damage rubber condoms. Patients using vaginal medicines should be aware of a possible adverse effect on rubber condoms or contraceptive diaphragms and a subsequent increased risk of pregnancy or contagious diseases such as AIDS. Fatty excipients such as glycerin, paraffin, petrolatum or Witepsol may be involved.

Effectiveness of Norplant implants through seven years: a large-scale study in China

The effectiveness of Norplant implants over a seven year period of continuous use was studied in a multicenter trial. Pregnancy rates were 0.4 per 100 in both year six and year seven. More than 3,600 women completed 6 years and more than 2,400 women completed 7 years. Pregnancy rates increased with weight (p < .05) and decreased with age, but in years 6 and 7 combined, the pregnancy rate neither reached nor exceeded 1 per 100 woman years in any 5 year age group or in any 10 kg weight group.

The impact on fertility of contraceptive failure in China in the 1980s

Contraceptive failure was an important determinant of fertility in China in the 1980s. Based on the data from the China Two-per-Thousand Fertility Survey, this study shows that about 7% of the general fertility rate of currently married women aged 15-49 for a 12-month period is attributed to contraceptive failure, mainly due to the high failure rate associated with IUD use. A number of demographic characteristics are associated with contraceptive use, and with contraceptive failure and its outcome. Relevant socioeconomic differentials are also identified.

Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia

OBJECTIVES

To determine the sexual risk behaviour and the incidence of sexually transmitted diseases (STD) among Dutch marines and naval personnel during a United Nations (UN) deployment.

METHODS

Surveillance by post deployment questionnaire, administered to 2289 persons in three successive battalions who served for 6 months on a UN deployment in Cambodia during June 1992-November 1993. On site the medical history of all individuals was kept up to date in a database. All personnel received extra education on STD prevention prior to deployment. Condoms were freely obtainable during deployment.

RESULTS

1885 persons (82%) handed in the questionnaire of whom 842 (45%) reported to have had sexual contacts with prostitutes or local population. Being younger and single were independent risk factors for having contact. Out of these 842 persons, 750 (89.1%) reported condom use at all times, while 82 (9.7%) reported inconsistent use and 10 persons (1.2%) reported not to have used condoms. Risk factors for inconsistent and non use were being 40 years or older and a higher number of contacts. From the 832 (750 + 82) condom users, 248 (30%) reported condom failure. Risk factors for failure were: inconsistent condom use, having had more than six contacts and being in the second battalion. The patient recording database showed 43 STD cases registered in the total population of 2289 persons (1.9%).

CONCLUSIONS

A low STD incidence was found despite a considerable number of reported sexual contacts. The reported condom use was high but the failure rate was considerable and needs further attention.

Unintended pregnancies and use, misuse and discontinuation of oral contraceptives

Unintended pregnancies are a recognized occurrence among women using oral contraceptives (OCs) as a consequence of both user and method failure. However, OCs also influence the occurrence of unintended pregnancies through an additional, poorly recognized, route: cessation of OC use by women who do not wish to become pregnant but stop using OCs because of side effects or other reasons. Many such women fail to immediately substitute a new contraceptive and/or adopt a less reliable contraceptive. This is a particularly important consideration for the approximately 3.7 million women who begin taking OCs in the United States each year since this group commonly experiences side effects and has a high discontinuation rate. Using a decision tree to follow a cohort of OC users over one year, we estimate that over 1 million unintended pregnancies are related to OC use, misuse or discontinuation. The greatest proportion of these, 61%, occur in women who discontinue OCs; of these, 66.6% occur in women who fail to immediately substitute other contraceptives and 33.3% because of the adoption of less reliable contraceptive methods. Of continuing OC users, the majority, exhibiting good compliance, contribute 24% of pregnancies because of their large numbers. Continuing OC users who are poor compliers, though many fewer, are responsible for 15% due to their high pregnancy rate. Unintended pregnancies in women who discontinue OCs account for approximately 20% of the 3.5 million annual unintended pregnancies in the United States, incurring costs of nearly +2.6 billion.(ABSTRACT TRUNCATED AT 250 WORDS)

Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation

The contraceptive efficacy of oral contraceptives (OCs) depends on their proper and continued use, particularly with lower estrogen preparations. However, few studies have examined why women miss pills or discontinue OCs, and those that do tend to be small and to focus on adolescents. To address the issues of poor OC compliance and early OC discontinuation, we analyzed OC use in a convenience sample of 6,676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom. Logistic regression was used to examine the independent effect of each factor. Poor compliance was associated with a lack of established routine for pill-taking (relative risk [RR] = 3.3), failure to read and understand written materials that came with the OC package (RR = 2.2), not receiving adequate information or help about OCs from their health care provider (RR = 1.5), and occurrence of certain side effects, including hirsutism (RR = 2.1), nausea (RR = 1.4), bleeding irregularities (RR = 1.3), and breast tenderness (RR = 1.2). Women who were inconsistent OC users, missing one or more pills per cycle, were almost three times as likely to experience an unintended pregnancy while using OCs than were women who took their OCs consistently. Factors that predicted early discontinuation (women who wished to continue contraceptive protection but discontinued OC use) were primarily side effects, including nausea (RR = 2.1), bleeding (RR = 1.9), breast tenderness (RR = 1.8), mood changes (RR = 1.8), and weight gain (RR = 1.4).(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness of the non-spermicidal fit-free diaphragm

Standard instructions for diaphragm use call for an individually sized latex diaphragm, used in conjunction with spermicide jelly. However, some investigators have reported that the diaphragm can be effective without a spermicide. A non-randomized trial designed to measure the contraceptive effectiveness of the diaphragm used without spermicide was conducted. A total of 110 self-selected women were enrolled to use a non-spermicide fit-free (60mm) diaphragm for a period of one year. They were advised to wear the diaphragm continuously, removing it once each day for washing but not within six hours after intercourse. Product-related problems related to insertion, retention and removal were few at both the 6- and 12-month follow-up visits, most commonly odor. The 12-month life table accidental pregnancy rate during typical use was 24.1 per 100 women (29.5 per 100 women without female barrier experience and 17.9 per 100 women with barrier experience). Over 85% of the women who returned for follow-up visits reported using the diaphragm during every act of intercourse. Until better data refute the traditional recommendations, users should be advised to add spermicide to fitted latex diaphragms.

Oral contraceptives and antibiotics: important considerations for dental practice

This paper considers the possible interactions between oral contraceptive pills and antibiotics, in the context of modern dental practice. A review of the literature on such interactions leads to the conclusion that current national guidelines on the use of alternative contraceptive measures during a course of broad spectrum antibiotics in women also using the oral contraceptive pill should be emphasised and encouraged as part of good clinical practice. A patient information leaflet may be considered as a useful way of presenting such advice to female patients.

Female sterilisation: National Women's Hospital 1988-9

AIM

To determine the failure rate of all female sterilisation procedures performed at National Women's Hospital in order to identify ways of improving the service.

METHODS

A review was made of all sterilisation procedures performed at National Women's Hospital in 1988 and 1989. All patient notes and theatre records were examined. A consumer questionnaire was mailed to all patients monthly for 3 months. If there was no response efforts were made to contact these women via their last known general practitioner. Epsom Day Hospital where 95% of all terminations of pregnancy in Auckland are performed also examined their records.

RESULTS

1094 procedures were performed at National Women's Hospital in Auckland during 1988 and 1989. Failures were classified into two groups: those pregnant at the time of surgical procedure (administrative failures) and those pregnant after the procedure (surgical failure). There were 15 surgical failures (1.4%). Laparoscopy using Filshie clips was the most common method used and had a 1.2% surgical failure rate. Registrars had a 1.3% failure rate, consultants 1.9% and when both a consultant and registrar performed the procedure a failure rate of 0.7% was recorded. Eighty-six percent (6/7) of women who had a subsequent laparotomy after a failed sterilisation were found to have surgical misapplication of the occlusive device. There were 7 (0.6%) women who were pregnant at the time of the procedure. There were no patient or procedure-related factors which were associated with failures.

CONCLUSION

Sterilisation is associated with a significant failure rate. Contraception counselling at the time of booking for the procedure needs to be improved. Preoperative pregnancy testing should be introduced to avoid sterilisation procedures in early pregnancy. Surgical misapplication of devices was a common cause of failure, not recanalisation as found elsewhere. From this review it would appear that the involvement of two surgeons lowers the failure rate.

Clinical performance of the TCu 380A and TCu 220C IUDs in four developing country family planning clinics

The clinical performance of the Copper T 380A (TCu 380A) and the Copper T 220C (TCu 220C) intrauterine devices (IUDs) were evaluated for 12 months in a group of women who had one of the two IUDs inserted. Results are from a randomized clinical trial conducted at four collaborating research sites located in two developing countries. The gross cumulative life-table pregnancy rate of the TCu 380A IUD was found to be lower than that of the TCu 220C IUD at 12 months (0.3 and 0.8, respectively), although this difference was not statistically significant (p > 0.05). Statistically significant differences between the two study IUDs were not found with regard to IUD expulsion or IUD removal due to bleeding/pain, personal reasons, medical reasons, or planned pregnancy. No statistically significant differences were observed in the frequency of experiencing menstrual disturbances (i.e., dysmenorrhea, intermenstrual pelvic pain or intermenstrual bleeding) between the two IUD groups. These data suggest that the TCu 380A and TCu 220C IUDs are both appropriate options for contracepting women. The TCu 380A IUD, however, may be a more appropriate option for those women wishing to space births over a longer period of time.

Breakage and slippage of condoms in family planning clients

Information was obtained from 540 clients on the 3,754 occasions when condoms were used over a one-month period. One or more major problems, breakage, slippage, leakage or a combination of these, occurred in 410 (10.9%) events, involving 217 (40.2%) clients. Breakage occurred in 209 (5.6%) events and slippage in 243 (6.5%). Leakage was almost always associated with breakage or slippage. There was a small group of accident prone clients. Breakage was more common in younger and inexperienced clients and in those who had previously experienced breakage. There were some differences in breakage rates between brands of condoms. Poor fitting condoms and non-spermicidal condoms were associated with more breaks. Other contributing factors included vigorous sex, dryness and tearing with fingernails. Additional lubrication did not protect from breaks and saliva was associated with more breaks than expected. Oil-based lubricants were associated with less breaks than expected. On many occasions (66.0%), clients were aware of the break before ejaculation occurred. Slippage was more common in the inexperienced and in those who had previously experienced slippage. There was no association between brand of condom and slippage but poor fitting condoms were associated with more slips. The most common reason for slippage was the condom being left on too long. Additional lubrication did not affect slippage.

Fatherhood without apparent spermatozoa after vasectomy

Fatherhood after vasectomy is rare. We describe 6 cases of DNA-proven fatherhood after vasectomy in association with persistently negative semen examination. All vasectomy patients and their partners should be counselled about the small possibility of late failure, and warning of failure should be recorded.

Practical problems which women encounter with available contraception in Australia

Australian women face major difficulties with contraception because of the limited range of choices, the need for meticulous attention to compliance with most available methods and because of cost limitations for a significant minority of the population. The most commonly used methods are oral contraceptive pills and barrier methods, and each has substantial compliance problems which can be minimized with care and counselling. There is an urgent need for a wider range of options in Australia and for good information and publicity about them. Present progress in this direction gives some hope for the near future.

Epidemiology of unintended pregnancy and contraceptive use

Almost all women are at risk for unintended pregnancy throughout their reproductive years. However, adolescents, formerly married women, and women of low socioeconomic status are at greater risk for contraceptive nonuse and for contraceptive failure; thus they are also at greater risk for unintended conceptions. Of the 6.4 million pregnancies occurring in the United States in 1988, more than half (56%) were unintended. An equal proportion of unintended pregnancies end in abortion (44%) as with birth (43%), and both options have great personal and social consequences. The level of unintended pregnancy appears to have increased during the last decade after consistent decreases since the early 1960s. Decreasing both the periods of contraceptive nonuse and contraceptive misuse will help lower the rate of unintended pregnancy in this country.