Provision of long-acting reversible contraception in HIV-prevalent countries: results from nationally representative surveys in southern Africa.

OBJECTIVE: To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings. DESIGN: Nationally representative survey of clinicians. SETTING: HIV-prevalent settings in South Africa and Zimbabwe. POPULATION: Clinicians in South Africa and Zimbabwe. METHODS: Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIV-prevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs. MAIN OUTCOME MEASURE: Multivariable logistic regression of contraceptive provision and clinician training needs. RESULTS: Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training. CONCLUSIONS: Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and at-risk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.

Unsafe abortion after legalisation in Nepal: a cross-sectional study of women presenting to hospitals.

OBJECTIVE: To investigate abortion practices of Nepali women requiring postabortion care. DESIGN: Cross-sectional study. SETTING: Four tertiary-care hospitals in urban and rural Nepal. SAMPLE: A total of 527 women presenting with complications from induced abortion in 2010. METHODS: Women completed questionnaires on their awareness of the legal status of abortion and their abortion-seeking experiences. The method of induction and whether the abortion was obtained from an uncertified source was documented. Multivariable logistic regression was used to identify associated factors. MAIN OUTCOME MEASURES: Induction method; uncertified abortion source. RESULTS: In all, 234 (44%) women were aware that abortion was legal in Nepal. Medically induced abortion was used by 359 (68%) women and, of these, 343 (89%) took unsafe, ineffective or unknown substances. Compared with women undergoing surgical abortion, women who had medical abortion were more likely to have obtained information from pharmacists (161/359, 45% versus 11/168, 7%, adjusted odds ratio [aOR] 8.1, 95% confidence interval 4.1-16.0) and to have informed no one about the abortion (28/359, 8% versus 3/168, 2%, aOR 5.5, 95% CI 1.1-26.9). Overall, 291 (81%) medical abortions and 50 (30%) surgical abortions were obtained from uncertified sources; these women were less likely to know that abortion was legal (122/341, 36% versus 112/186, 60%, aOR 0.4, 95% CI 0.2-0.7) and more likely to choose a method because it was available nearby (209/341, 61% versus 62/186, 33%, aOR 2.5, 95% CI 1.5-4.3), compared with women accessing certified sources. CONCLUSIONS: Among women presenting to hospitals in Nepal with complications following induced abortion of pregnancy, the majority had undergone medically induced abortions using unknown substances acquired from uncertified sources. Women using medications and those accessing uncertified providers were less aware that abortion is now legal in Nepal. These findings highlight the need for continued improvements in the provision and awareness of abortion services in Nepal.

Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings.

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

Advance provision of emergency contraception for pregnancy prevention (full review).

BACKGROUND: Emergency contraception can prevent pregnancy when taken after unprotected intercourse. Obtaining emergency contraception within the recommended time frame is difficult for many women. Advance provision, in which women receive a supply of emergency contraception before unprotected sex, could circumvent some obstacles to timely use. OBJECTIVES: To summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors. SEARCH STRATEGY: In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE via PubMed, and a specialized emergency contraception article database. We also searched reference lists and contacted experts to identify additional published or unpublished trials. SELECTION CRITERIA: We included randomized controlled trials comparing advance provision and standard access, which was defined as any of the following: counseling which may or may not have included information about emergency contraception, or provision of emergency contraception on request at a clinic or pharmacy. DATA COLLECTION AND ANALYSIS: We evaluated all identified titles and abstracts found for potential inclusion. Two reviewers independently abstracted data and assessed study quality. We entered and analyzed data using RevMan 4.2.8. We calculated odds ratios with 95% confidence intervals for dichotomous data and weighted mean differences with 95% confidence intervals for continuous data. MAIN RESULTS: Eight randomized controlled trials met our criteria for inclusion, representing 6389 patients in the United States, China and India. Advance provision did not decrease pregnancy rates (OR 1.0; 95% CI: 0.78 to 1.29 in studies for which we included twelve month follow-up data; OR 0.91; 95% CI: 0.69 to 1.19 in studies for which we included six month follow-up data; OR 0.49; 95% CI: 0.09 to 2.74 in a study with three month follow up data), despite increased use (single use: OR 2.52; 95% CI 1.72 to 3.70; multiple use: OR 4.13; 95% CI 1.77 to 9.63) and faster use (weighted mean difference (WMD) -14.6 hours; 95% CI -16.77 to -12.4 hours). Advance provision did not lead to increased rates of sexually transmitted infections (OR 0.99; 95% CI 0.73 to 1.34), increased frequency of unprotected intercourse, nor changes in contraceptive methods. Women who received emergency contraception in advance were equally as likely to use condoms as other women. AUTHORS' CONCLUSIONS: Advance provision of emergency contraception did not reduce pregnancy rates when compared to conventional provision. Advance provision does not negatively impact sexual and reproductive health behaviors and outcomes. Women should have easy access to emergency contraception, because it can decrease the chance of pregnancy. However, the interventions tested thus far have not reduced overall pregnancy rates in the populations studied.

Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence.

Clinical breast and pelvic examinations are commonly accepted practices prior to provision of hormonal contraception. Such examinations, however, may reduce access to highly effective contraceptive methods, and may therefore increase women's overall health risks. These unnecessary requirements also involve ethical considerations and unwittingly reinforce the widely held but incorrect perception that hormonal contraceptive methods are dangerous. This article reviews and summarizes the relevant medical literature and policy statements from major organizations active in the field of contraception. Consensus developed during the last decade supports a change in practice: hormonal contraception can safely be provided based on careful review of medical history and blood pressure measurement. For most women, no further evaluation is necessary. Pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted infection, while important in their own right, do not provide information necessary for identifying women who should avoid hormonal contraceptives or who need further evaluation before making a decision about their use.

Alterations in phosphatidylcholine metabolism of stretch-injured cultured rat astrocytes.

The primary objective of this study was to determine the influence of stretch-induced cell injury on the metabolism of cellular phosphatidylcholine (PC). Neonatal rat astrocytes were grown to confluency in Silastic-bottomed tissue culture wells in medium that was usually supplemented with 10 microM unlabeled arachidonate. Cell injury was produced by stretching (5-10 mm) the Silastic membrane with a 50-ms pulse of compressed air. Stretch-induced cell injury increased the incorporation of [3H]choline into PC in an incubation time- and stretch magnitude-dependent manner. PC biosynthesis was increased three- to fourfold between 1.5 and 4.5 h after injury and returned to control levels by 24 h postinjury. Stretch-induced cell injury also increased the activity of several enzymes involved in the hydrolysis [phospholipase A2 (EC 3.1.1.4) and C (PLC; EC 3.1.4.3)] and biosynthesis [phosphocholine cytidylyltransferase (PCT; EC 2.7.7.15)] of PC. Stretch-induced increases in PC biosynthesis and PCT activity correlated well (r = 0.983) and were significantly reduced by pretreating (1 h) the cells with an iron chelator (deferoxamine) or scavengers of reactive oxygen species such as superoxide dismutase and catalase. The stretch-dependent increase in PC biosynthesis was also reduced by antioxidants (vitamin E, vitamin E succinate, vitamin E phosphate, melatonin, and n-acetylcysteine). Arachidonate-enriched cells were more susceptible to stretch-induced injury because lactate dehydrogenase release and PC biosynthesis were significantly less in non-arachidonate-enriched cells. In summary, the data suggest that stretch-induced cell injury is (a) a result of an increase in the cellular level of hydroxyl radicals produced by an iron-catalyzed Haber-Weiss reaction, (b) due in part to the interaction of oxyradicals with the polyunsaturated fatty acids of cellular phospholipids such as PC, and (c) reversible as long as the cell's membrane repair functions (PC hydrolysis and biosynthesis) are sufficient to repair injured membranes. These results suggest that stretch-induced cell injury in vitro may mimic in part experimental traumatic brain injury in vivo because alterations in cellular PC biosynthesis and PLC activity are similar in both models. Therefore, this in vitro model of stretch-induced injury may supplement or be a reasonable alternative to some in vivo models of brain injury for determining the mechanisms by which traumatic cell injury results in cell dysfunction.

The emergency contraceptive pill: a survey of knowledge and attitudes among students at Princeton University.

OBJECTIVE: Our purpose was to measure and analyze knowledge and attitudes about emergency contraceptive pills. The hypothesis we tested was that more accurate knowledge about the regimen would be associated with favorable attitudes towards its use. STUDY DESIGN: We conducted a random sample telephone survey and a series of focus group discussions at Princeton University (results for 11 focus groups are presented elsewhere) A total of 550 undergraduate and graduate students were selected randomly for participation in the survey, and the response rate was 82%. The study's primary outcome measure was attitudes toward the emergency contraceptive pill as a method of fertility control. We used multivariate regression analysis with ordered logit models to test the hypothesized association between knowledge and attitudes. RESULTS: Basic awareness and approval of the emergency contraceptive pill were widespread, yet students lacked detailed knowledge, which did contribute to health and ethical misgivings about the regimen. Students with accurate information, especially those students who knew that the therapy is a large dose of regular oral contraceptives and that side effects are generally minor, were significantly more likely than others to report favorable attitudes. Many students confused the pills dispensed by the university health services (Oral, Wyeth-Ayerst, Philadelphia) with the abortifacient RU 486. Students noted discussion of the method is rare, and many wanted to know more about it. Statistical results are reported with a 95% confidence level. CONCLUSIONS: Educational efforts should offer specific information about the composition of emergency contraceptive pills, the side effects, and how the regimen works.

PIP: A random survey was conducted using the campus voice mail system among 550 students of Princeton University to determine their knowledge of and attitudes about postcoital contraception (which has been available at the university health center for more than 15 years). The survey elicited a response rate of 82% and included demographic information in the data collected. The results showed that 95% (98% of the undergraduates) of the sample knew about emergency oral contraception (EOC), but 52% of the respondents could not distinguish EOC from RU-486, only 38% knew that the correct time of use was within 72 hours, only 26% knew that EOC was a regimen which used a large dose of combined oral contraceptives, and 25% knew that the effectiveness of EOC is 75%. 54% of the students believed that EOC is associated with unpleasant side effects, and 7% thought there would be serious side effects (this attitude was significantly related to nonendorsement). Only 12% of the students correctly identified the fertile period in the menstrual cycle and understood the timing factors associated with EOC. 80% of the students approved of EOC, and 91% approved in cases of rape. Those who identified themselves as Democrats were significantly more likely to approve, and those who were highly religious were significantly less likely. Ethical concerns were cited by 32% of the respondents, and 57% had health concerns. 84% felt that EOC was readily accessible, but only 43% knew it was available throughout the week. 30% of the students had experience with a situation in which more information about EOC would have been helpful. Regression analysis of these findings revealed that approval was higher among students who knew the ingredients and side effects of EOC, knew of a situation where it would have been helpful, were not religious, and/or were Democrats. Ethical concerns were associated with health concerns, strong religious feeling, Republican affiliation, and a lack of knowledge about ingredients.

Stimulation by target cell membrane lipid of actin polymerization and phagocytosis by Entamoeba histolytica.

The identity of molecules of mammalian target cells that stimulate contact-dependent attack by Entamoeba histolytica was sought using human erythrocytes (RBC) as a model. Protein-free liposomes prepared from RBC membrane lipids stimulated the same rapid E. histolytica actin polymerization and phagocytosis as did whole target cells. Liposomes constructed from the major phospholipids of RBC stimulated these responses but only if a negatively charged phospholipid was included. The addition to these liposomes of digalactosyl diglyceride significantly enhanced their stimulatory activity. The results demonstrate that ligands that trigger attack-related responses by E. histolytica reside in the target cell membrane lipid fraction and suggest roles for both glycolipid and phospholipid components.