Utilisation and outcomes of cervical cancer prevention services among HIV-infected women in Cape Town

OBJECTIVE

An audit of outcomes of cervical cancer screening and prevention services for HIV-positive women in Cape Town, South Africa.

DESIGN

Retrospective review of clinic registers, patient records and pathology databases at three HIV primary health clinics and a tertiary colposcopy referral centre.

SUBJECTS

Women recently diagnosed with HIV at three primary health clinics between 2006 and 2008 (N=2 240); new patients seen for colposcopy at a tertiary referral centre between 2006 and 2009 (N=2 031).

OUTCOME MEASURES

The proportion of women undergoing cervical cancer screening after HIV diagnosis at primary health clinics, demographic characteristics of women referred for colposcopy at a tertiary centre, and outcomes of therapy for precancerous lesions of the cervix.

RESULTS

The proportion of women undergoing at least one Pap smear at HIV primary health clinics after HIV diagnosis was low (13.1%). Women referred for colposcopy tended to be HIV-positive and over the age of 30 years, and in most (70.2%) cytological examination revealed high-grade cervical dysplasia. HIV-positive women treated with excision for precancerous lesions of the cervix were significantly more likely than their HIV-negative counterparts to undergo incomplete excision, experience persistent cervical disease after treatment, and be lost to follow-up.

CONCLUSION

Cervical cancer screening efforts must be scaled up for women with HIV. Treatment and surveillance guidelines for cervical intraepithelial neoplasia in HIV-positive women may need to be revised and new interventions developed to reduce incomplete treatment and patient default.

Financial risks associated with healthcare consumption in Jinja, Uganda

INTRODUCTION

Financial access to promotive, preventive, curative and rehabilitative healthcare by every one remains a challenge globally. The requirement to make direct payments at the time of consuming health services is one of the reasons why it persists. In this paper, we present findings on the financial risks households bear as a result of healthcare consumption in one district in Uganda.

METHODOLOGY

Using simple random sampling, we selected 384 household heads in 3 health sub districts. A structured questionnaire was to conduct the survey. Focus group discussions and Key Informant interviews were also conducted.

RESULTS

Up to 77% (297/384) of households reported making direct payments for healthcare when a household member fell ill, 45% (174/384) did so each time a household member fell ill. Payment for healthcare was associated with employment of the household head in the informal sector (OR 1.6, 95% 1.2-2.1), presence of children OR 1.5, 95% 1.3-1.9 or someone with chronic illness OR 3, 95% 1.5-6 respectively and history of hospitalization (OR 3, 95% 1.7-6.5).

CONCLUSION

A high burden of healthcare needs, disproportionately affect children and women among households in Jinja. Direct payments for healthcare still occur in spite of the abolishment of user fees at public health facilities and tax based financing of health services in Uganda.

[Post-term pregnancy and associated social factors among pregnant women in Jiaxing city, China, 1993 to 2000]

OBJECTIVE

To understand the status of post-term pregnancy and associated social factors among pregnant women in Jiaxing city, from 1993 to 2000.

METHODS

The study population consisted of 16 033 women who had delivered singleton live births in Jiaxing city,Zhejiang province, from 1993 to 2000. Chi-square test was employed to test the difference of proportions between respective groups. Multivariate logistic regression was conducted to examine the factors associated with post-term pregnancy.

RESULTS

The incidence rates of post-term pregnancy were 8.7%, 10.6%, 9.4%, 7.4%, 4.3%, 2.6%, 3.3% and 4.0% from 1993 to 2000, respectively. Women who received premarital health care services had lower (5.6%) post-term incidence than those who did not (7.8%). Women who received county or above level health care services had lower (4.3%) post-term incidence than women who receive township level service (8.5%). Women who had primary school education had higher (11.5%) post-term incidence than women who received junior higher school education (6.8%), senior high school education (3.8%), or college education (2.9%), (P<0.001). Farmers had higher (9.5%) post-term incidence than workers in the rural areas (8.9%), in urban areas (4.3%) or women with other professions (4.2%). Women whose husbands were rural workers had higher (9.8%) post-term incidence than farmers (9.4%), urban workers (5.0%) or with other professions (3.6%, P<0.001). Data from multivariate logistic regression showed that the risk of post-term pregnancy was associated with the length and the level of using health care services together with schooling and occupation.

CONCLUSION

The incidence of post-term pregnancy was decreasing in Jiaxing city during the period from 1993 to 2000 and the risk was associated with the length and level of health care service as well as the level of education and occupation of those women.

[An eight-year study on maternal and child health service utility in Sichuan province]

OBJECTIVE

To evaluate the effect of intervention on factors influencing the health service utility regarding Maternal and Child Health (MCH) under the 'Qinba Health Project' in Sichuan province.

METHODS

15 towns in 5 programmed counties were selected, using the method of 'random layer sampling' to be the trial group. With similar MCH status and comparable to the trial group, another 9 towns in 3 non-programmed counties were chosen as the control group, using the same sampling method. Indicators on MCH service utility were compared with that in the control group, and the influencing factors of MCH service utility analyzed by logistic model.

RESULTS

The main characteristics of the two groups were quite similar at the baseline study, with the average annual family incomes and MCH service per 1000 people. Annual input on MCH services from the government had an distinct increase. The average annual rates of increase regarding the indicators as clean delivery, hospitalized delivery, systematic care on maternal and children, maternal and infant mortality rates were: 1.95%, 9.34%, 4.82%, 3.04%, -2.67%, -13.84% (P < 0.02) through chi2 trend tests. In the trial group, the changes seen in the 6 indicators were better in the control group than in the control group (P < 0.05). Data from the logistic regression model showed that the major influencing factors on the use of hospitalized delivery service were: age of the pregnant woman, average annual income of the family, health insurance status, number of pre-delivery visits, whether on poverty alleviate program, and on knowledge of MCH.

CONCLUSION

The intervention project in this programmed area seemed effective and better than the non-programmed area, through an eight-year observation.

Outcomes for abdominal myomectomies among high-volume surgeons

OBJECTIVE

To examine the relationship between surgical volume and complications and resource utilization for myomectomy.

STUDY DESIGN

This retrospective cross-sectional study in a university hospital setting (Brigham and Women's Hospital) analyzed 527 consecutive women with uterine fibroids who underwent abdominal myomectomy. A multivariate analysis was performed to determine the association between surgical volume and outcomes.

RESULTS

There were no significant medical or surgical complications following myomectomy. However, high-volume surgeons did procedures significantly faster, they collected more tissue per time and their patients had less blood loss.

CONCLUSION

The surgical volume of the physician does not affect the safety of abdominal myomectomy. However, high-volume surgeons had more efficient resource utilization than did physicians doing fewer cases.

Methods for estimating medical expenditures attributable to intimate partner violence

This article compares three methods for estimating the medical cost burden of intimate partner violence against U.S. adult women (18 years and older), 1 year postvictimization. To compute the estimates, prevalence data from the National Violence Against Women Survey are combined with cost data from the Medical Expenditure Panel Survey, the Medicare 5% sample, and published studies and with relative risk estimates from published studies. Results are compared and reasons for difference are explored, including the advantages and disadvantages of each approach. Estimates of the medical cost burden of intimate partner violence within the first 12 months after victimization range from USD 2.3 billion to USD 7.0 billion, depending on the method used. Although limited to women victimized in the last year, each method reveals that intimate partner violence imposes a substantial burden on the health care system. Among the approaches, there is no clear gold standard nor any evidence of bias.

Unsafe abortion in Kenya

Though pregnancy termination is highly restricted in Kenya, induced abortion remains common. Illegal abortion is often unsafe, putting women at risk of death or severe complications. In eastern Africa as a whole, an estimated 14% of all pregnancies end in abortion, and nearly one in five maternal deaths are due to unsafe abortion.

Utilization of fertility-related services in the United States

To describe trends in the types of fertility-related medical services that women and/or their partners have received while trying to become pregnant, the author analyzed data from women aged 20-44 years who participated in the 2002 National Survey of Family Growth. Advice (74%) and infertility testing (59%) were the most common types of fertility-related services received, and of those who received infertility testing, 66% responded that both partners were tested. Nearly half of the study population reported receiving drugs to improve ovulation.

Evaluation of cervical cancer screening program at a rural community of South Africa

OBJECTIVE

Cervical cancer is a leading cause of deaths among women worldwide. But the condition is preventable through regular screening of women those are 'at risk' for abnormal changes in the cervix and treating them who have positive results. Although screening facilities are available in South Africa, the incidence and mortality from cervical cancer remains very high and many women present health facilities with late stage diseases. Purpose of the study is to determine the baseline information on knowledge and practices on risk factors for cervical cancer and Pap smear and to design an intervention to improve Pap smear uptake.

METHODS

A cross-sectional population based descriptive study was undertaken at a rural community of South Africa targeting women 30 years and over. The assessment was performed by means of a questionnaire survey. Outcome measures were percentage of women with the knowledge on risk factors for cervical cancer and use of Pap smear test and had undertaken Pap smear test. Binary logistic regression analysis was carried out to identify possible predictors of Pap smear test undertaken. A total of 611 women (random samples) were recruited from the selected households.

RESULTS

The mean age of the sample was 43 years and 54% of them had no education. Only 6% knew all and 65% knew any one of the risk factors of cervical cancer whereas less than half (49%) of them knew that Pap smear is used for prevention of cervical cancer. Only 43% respondents received information on Pap smear from health care workers. Among all the respondents only 18% (95% CI, 15-21) had ever done Pap smear test.

CONCLUSIONS

This study showed low uptake of Pap smear test and low level of knowledge on prevention of cervical cancer and risk factors thus warrants urgent extensive health education program for this rural communities.

Gender-associated violence at a women's hospital in Nairobi, Kenya

OBJECTIVE

To describe the pattern of gender-associated violence amongst adult survivors.

DESIGN

Descriptive case analysis of prospectively collected data.

SETTING

The gender violence and recovery centre (GVRC), a shelter and violence treatment facility for the gender-associated violence at the Nairobi Women's hospital (NWH).

SUBJECTS

Data on 663 consecutive adult patients who presented to GVRC between February 2003 and April 2004 were evaluated.

RESULTS

The patients age ranged from 18 to 74 years (mean 27.7 years). Four hundred and eight patients (61.5%) presented following sexual assault. Most of assaults were perpetrated at night. A stranger was the assault perpetrator in 75.1% and 2% of sexual and non-sexual assault respectively. An intimate partner was the perpetrator in majority (86.5%) of nonsexual violence. Most physical injuries were minor bruises and swellings. The rate of positive spermatozoa from high vaginal swabs was only 15.9% in cases of sexual assault. Sexual assault was significantly associated with single status of the victim and assault by more than one assailant.

CONCLUSIONS

Violence against women is a common public health problem in the city of Nairobi. Women are vulnerable both in and out of the home. More efforts, including massive public education, are needed to protect this vulnerable population.

Trends of determinants of hormone therapy use in Italian women attending menopause clinics, 1997-2003

OBJECTIVE

Analysis of patterns of hormone therapy (HT) use among postmenopausal Italian women, before and after publication of results from the Heart and Estrogen/progestin Replacement Study and the Women's Health Initiative.

DESIGN

This was a cross-sectional study conducted between 1997 and 2003 on the characteristics of women around the age of menopause. The study population consisted of 106,784 women (mean age 53 y) attending menopause clinics in Italy. Postmenopausal women were defined as women with surgical menopause (ie, bilateral oophorectomy with or without hysterectomy), women older than 55 years who underwent hysterectomy without bilateral oophorectomy, and women whose menstrual cycles had stopped more than 1 year before their interview.

RESULTS

A total of 15,657 women (14.7%) reported ever using HT. The prevalence of HT prescription was 17.6% among women observed in 1997-1998, 14.9% in 1999, 12.2% in 2000, 12.1% in 2001, and 11.4% in 2002-2003. HT use was related to age at menopause and level of education in all the periods considered and was more frequent in women reporting surgical menopause. The odds ratio of HT prescription tended to decrease in women with surgical menopause, with slight fluctuations in the intermediate years. Ever users of oral contraceptives and nulliparae were more frequently HT users.

CONCLUSIONS

In our population the percentage of current HT users dropped from 17.6% in 1997-1998 to 11.4% in 2002-2003. However, the determinants of use were largely unchanged during the study period: women with higher education, nulliparae, and smokers reported more frequent HT use.

Maternal healthcare needs assessment survey at Rabia Balkhi Hospital in Kabul, Afghanistan

OBJECTIVE

Since the Department of Health and Human Services chose Rabia Balkhi Hospital (RBH) in Kabul, Afghanistan, as a site for intervention in 2002, the status of women's health there has been of interest. This study created a tool to assess accessibility and quality of care of women admitted from May to July, 2005.

METHODS

A 39-item questionnaire was created in English and translated into Dari. Hospital staff administered the survey to 292 women admitted to RBH for obstetric and gynecological complaints.

RESULTS

Approximately 40% of the women traveled between 1 and 5 hours to reach RBH. Only 54% (158/292) of women reported having their blood pressure monitored during their pregnancy. About one-third of women reported that they had never received an immunization.

CONCLUSIONS

This survey tool ascertained that women who received care at RBH traveled great lengths to reach the facility. Preventative measures such as blood pressure checks and immunizations are areas that need improvement.

Reducing unsafe abortion in Nigeria

Abortion is illegal in Nigeria except to save a woman's life. It is also common, and most procedures are performed under unsafe, clandestine conditions. In 1996, an estimated 610,000 abortions occurred (25 per 1,000 women of childbearing age), of which 142,000 resulted in complications severe enough to require hospitalization. The number of abortions is estimated to have risen to 760,000 in 2006. Unsafe abortions are a major reason Nigeria's maternal mortality rate--1,100 deaths per 100,000 live births--is one the world's highest. According to conservative estimates, more than 3,000 women die annually in Nigeria as a result of unsafe abortion.

Women's health measures in two North Carolina regions sampled from the Basic Automated Birth Yearbook (BABY) datasets: experimental findings, methodological limits and future directions

PURPOSE

To compare selected characteristics in two North Carolina counties to document women's health services at the geographical extremes of the state.

METHODS

Using aggregated 2004 data obtained from the North Carolina State Center for Health Statistics, obstetric and perinatal characteristics were experimentally analyzed for the westernmost and easternmost counties in North Carolina (Cherokee and Dare County, respectively).

FINDINGS

During the experiment period, 489 infants were delivered in Dare County (population 33,518), while 259 births were recorded in Cherokee County (population 25,289). Prenatal care was established by most women in both counties by the second gestational month. Women in Cherokee County were younger and less educated at delivery than women in Dare County, and smoking prevalence was higher in Cherokee County than in Dare County (31.3% vs 12.9%; p <0.01). Cherokee County infants required assisted ventilation and other medical interventions more often than babies born in Dare County (p <0.01) yet significantly fewer cesarean deliveries were performed in Cherokee County than Dare County (25.5% vs 35.2%; p = 0.04).

CONCLUSION

This pilot study showed a significantly higher rate of tobacco use, and lower maternal education level in Cherokee County was associated with a higher incidence of multiple maternal complications and neonatal interventions compared to Dare County. Interestingly, the cesarean delivery rate was lower in Cherokee County despite these factors. We found < 10% of babies born in the study regions required any neonatal intervention. Early and almost universal access to prenatal care did not appear to be a problem at either site. Our preliminary comparison identified important limitations in this government-sponsored dataset that rendered logistic regression analysis methodologically impossible. Changes in process could improve surveillance based on patient-level data and facilitate multivariate analysis. Specific interventions to optimize women's health services form the basis of future experimental research, including larger regional populations.

Women's access to health care in Ghana: effects of education, residence, lineage and self-determination

Women's physical and psychological access to health care was analyzed using the 2003 Ghana Demographic and Health Survey (GDHS), a nationally representative study for monitoring population and health in Ghana. Female respondents from the 2133 cases in the couple's data set were used in this study. Women's level of education was positively related to physical but not to psychological access to health care. Residing in an urban area was positively related to both types of access. Matriliny consistently showed positive effects on physical access. In addition to these demographic factors, both physical and psychological access were positively related to women's self-determination, i.e., women's right and ability to make real choices about their lives including their health, fertility, sexuality, childcare and all areas where women are denied autonomy and dignity in their identities as women. Self-determination factors both mediated the effects of background factors on access and added explanatory power to the models.

The quality of family planning services in the United States: findings from a literature review

CONTEXT

Family planning services are frequently used and important services for American women, yet little is known about their quality. Service quality has important implications for women's reproductive health. If women do not receive adequate information and tools, and learn appropriate skills, from their providers, they may be hampered in their efforts to control their fertility.

METHODS

A variety of strategies, including database, journal and Internet searches, were used to identify published and unpublished U.S. studies on family planning service quality that came out between 1985 and 2005. Studies were categorized by their focus, and key points of their methodologies and findings were assessed.

RESULTS

Twenty-nine studies were identified, most of which were based on client surveys. Most conceptualized quality as a multidimensional construct, but a uniform definition of quality is lacking, and the domains studied have not been consistent. The available studies focus on four areas: assessments of quality, its correlates, its consequences for client behavior and attitudes, and clients' values and preferences regarding services. Relations between clients and service facility staff have typically been rated favorably, but communication, patient-centeredness and efficiency have been rated more poorly. Service quality varies by characteristics of the facility, provider, client and visit. Research on the consequences of service quality for clients' contraceptive behavior or risk of unintended pregnancy has been very limited and yielded mixed results.

CONCLUSIONS

Studies that assess service quality need stronger designs and greater consistency in measures used so that results are comparable.

The association of health insurance with use of prescription contraceptives

CONTEXT

Given that substantial proportions of women of reproductive age lack health insurance coverage, it is important to assess whether lack of insurance is associated with the use of prescription contraceptives, which are the most expensive but also the most effective methods for preventing pregnancy.

METHODS

Data from 26,674 females aged 18-44 who participated in the 2002 Behavioral Risk Factor Surveillance System survey (representing more than 25 million women in the U.S. population) were used to assess risk of unintended pregnancy, prescription contraceptive use and health insurance status. Logistic regression models tested the likelihood of prescription contraceptive use among insured versus uninsured respondents after controlling for socioeconomic characteristics and self-reported overall health.

RESULTS

A significantly higher proportion of insured women than of uninsured women reported use of prescription contraceptives (54% vs. 45%). In multiple regression analysis, women lacking health insurance were 30% less likely to report using prescription contraceptive methods than were women with private or public health insurance. Results were similar across racial, age and income subgroups.

CONCLUSIONS

Lack of health insurance is associated with reduced use of prescription contraceptives. Universal insurance coverage is needed to ensure access to the most effective contraceptive methods for all women in need.

The NSW Health routine screening for domestic violence program

Routine questioning of women about abuse by their intimate partner has been progressively introduced in NSW in antenatal, early childhood, alcohol and other drug and mental health services since 2001. This was done because of the serious health consequences of domestic violence and the low identification rate of abuse by health services. Following a pilot that found strong support from female patients, this strategy is now well established in NSW public health services. Recent data indicate that approximately 10,000 women a month are asked these questions and that 7.3% of them report experiences of physical abuse or fear caused by their partner or ex-partner within the past 12 months.

Preventive health examinations and preventive gynecological examinations in the United States

BACKGROUND

Preventive health examinations (PHEs) are controversial, and limited data are available on their use and content.

METHODS

We conducted a retrospective analysis of 8413 ambulatory visits from January 1, 2002, to December 31, 2004, for PHEs and preventive gynecological examinations (PGEs) by adults in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Population estimates were obtained from the Current Population Survey. We estimated rates of PHEs and PGEs by patients' demographic characteristics, the frequency of 8 preventive services provided at these visits, and total costs of PHEs and PGEs at Medicare reimbursement rates.

RESULTS

An estimated 44.4 million adults per year (20.9%; 95% confidence interval [CI], 18.2%-23.6%) received a PHE, and 19.4 million women per year (17.7% of adult women; 95% CI, 14.9%-20.4%) received a PGE, together accounting for 8.0% of all ambulatory visits. The PHE rates varied by region (Northeast vs West: relative risk, 1.58; 95% CI, 1.17-2.14) and insurance type (those without vs those with private insurance or Medicare: relative risk, 0.51; 95% CI, 0.40-0.65). Preventive services occurred at 52.9% (95% CI, 48.8%-57.0%) of PHEs and 83.5% (95% CI, 80.7%-86.3%) of PGEs, but only 19.9% (95% CI, 18.4%-21.5%) of 8 preventive services occurred at a PHE or PGE. The annual costs of these visits were approximately $7.8 billion.

CONCLUSIONS

PHEs and PGEs are among the most common reasons adults see a physician. These visits frequently include preventive services, but most preventive services are provided at other visits. These findings provide a foundation for continuing national deliberations about the use and content of PHEs and PGEs.

Routine preventive services for older women: a composite measure highlights gaps in delivery

BACKGROUND

We used a composite measure to examine the delivery of routine clinical preventive services to U.S. women aged 50-64 years and > or =65 years in 2004.

METHODS

We analyzed state data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) and created a composite measure that included screening of women > or =50 years for colorectal cancer, cervical cancer, breast cancer, vaccination against influenza, and, for women aged > or =65 years only, pneumococcal vaccination. The composite measure quantified the percentage of women who were up-to-date (UTD) according to recommended schedules for these services.

RESULTS

Approximately 23% of women aged 50-64 years and 32.5% of women aged > or =65 years were UTD in 2004. Results varied by education, race/ethnicity, marriage status, insurance status, and health status. There was also considerable geographic variation in state-specific UTD estimates, ranging from 16.7% (California) to 38.4% (Minnesota) for women aged 50-64 years and from 25.7% (Indiana) to 48.5% (Minnesota) for women aged > or =65 years.

CONCLUSIONS

Although rates for some individual services were > or =75%, the percentage of women aged 50-64 years and > or =65 years UTD on all routinely recommended cancer screenings and vaccinations was low, with <1 in 3 being UTD.

Cervical cancer screening and management practices among providers in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

BACKGROUND

This study was conducted to describe clinicians serving women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) with regard to demographic and practice characteristics and their usual practices in cervical cancer screening and abnormal cytology management, as well as human papillomavirus (HPV) test use.

METHODS

The authors analyzed data from a nationally representative survey conducted in 2004 of providers practicing 7 specialties that commonly offer cervical cancer screening. The program providers were compared with nonprogram providers.

RESULTS

Program providers were found to be significantly more likely than nonprogram providers to be midlevel providers and to serve low-income, racial/ethnic minorities who are insured by Medicaid. In addition, they had significantly more patients with abnormal Papanicolaou tests and were more likely to offer onsite colposcopy (57% vs 40%). Program providers were less likely to use liquid-based cytology (LBC) as their sole method for cytology. Approximately 20% of program and nonprogram providers used HPV DNA testing as an adjunct to screening cytology and two-thirds used HPV tests to manage patients with abnormal cytology results. However, many also used HPV testing for reasons not approved by the U.S. Food and Drug Administration (FDA), such as for screening women age <30 years.

CONCLUSIONS

As of mid-2004, program providers served racially and ethnically diverse, low-income patients who are at high risk for cervical cancer compared with nonprogram providers, as intended by this program. Because many providers offered on-site colposcopy, used LBC, and used HPV tests for patients with abnormal cytology results, they are well equipped to reduce the risk of cervical cancer. Many program providers used the HPV test for reasons that were not approved of by the FDA or reimbursed by the NBCCEDP. The results of this survey have informed training materials for program providers, reimbursement policies for LBC and HPV tests, and interventions to discourage inappropriate HPV testing.

Effect of Childhood Sexual Abuse on Gynecologic Care as an Adult

The study sought to evaluate whether childhood sexual abuse (CSA) experiences significantly affect the gynecologic care received as an adult. A self-administered questionnaire including eight questions on CSA was completed by 85 women exposed to CSA and 170 matched-control women. Women exposed to CSA experienced gynecologic examinations as anxiety-provoking significantly more often and sought more treatment for acute gynecologic problems; 43.5% of these women experienced memories of the original abuse situation during gynecologic consultations. Gynecologic care is particularly distressing for women exposed to CSA.