Improving manual vacuum aspiration service delivery, introducing misoprostol for cases of incomplete abortion, and strengthening postabortion contraception in Bangladesh.

The Obstetrical and Gynaecological Society of Bangladesh was an important advocate in mobilizing government authorities to adopt new techniques for postabortion care and provide long-acting contraceptives post abortion. With the support of the International Federation of Gynecology and Obstetrics (FIGO), the Society provided commodities and training to increase the use of these techniques in 7 private and public hospitals and clinics. Data from two of these institutes for the January 2012 to June 2013 period showed a rapid decrease in the use of dilation and curettage, an increase in the use of manual vacuum aspiration (MVA) and misoprostol, and the progressive adoption of long-acting reversible contraceptives, permanent contraception, and injectable contraceptives in one of these two hospitals. The Directorates General of Health and Family Planning incorporated training in the use of MVA and misoprostol in their national operation plans. The success in these hospitals shows that the proposed changes have been well accepted by providers and clients.

Achievements of the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences in South-Southeast Asia.

Since 2008, the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences has contributed to ensuring the substitution of sharp curettage by manual vacuum aspiration (MVA) and medical abortion in selected hospitals in participating countries of South-Southeast Asia. This initiative facilitated the registration of misoprostol in Pakistan and Bangladesh, and the approval of mifepristone for "menstrual regulation" in Bangladesh. The Pakistan Nursing Council agreed to include MVA and medical abortion in the midwifery curriculum. The Bangladesh Government has approved the training of nurses and paramedics in the use of MVA to treat incomplete abortion in selected cases. The Sri Lanka College of Obstetricians and Gynaecologists, in collaboration with partners, has presented a draft petition to the relevant authorities appealing for them to liberalize the abortion law in cases of rape and incest or when lethal congenital abnormalities are present. Significantly, the initiative has introduced or strengthened the provision of postabortion contraception.

Replacement of dilation and curettage/evacuation by manual vacuum aspiration and medical abortion, and the introduction of postabortion contraception in Pakistan.

Manual vacuum aspiration (MVA) and medical abortion were introduced to replace dilation and curettage/evacuation for incomplete abortions, and postabortion contraception was provided in 5 selected public hospitals in Pakistan. In the largest hospital, an Ipas MVA training center since 2007, MVA use reached 21% in 2008. After the International Federation of Gynecology and Obstetrics (FIGO) and UNFPA provided MVA kits, MVA use increased dramatically to 70%-90% in 2010-2013. In 2 of the remaining 4 hospitals in which the Society of Obstetricians and Gynecologists of Pakistan trained doctors in May 2012 and January 2013, the target of having 50% of women managed by MVA and medical abortion (MA) was met; however, in the third hospital only 43% were treated with MVA and MA. In the fourth hospital, where misoprostol and electric vacuum aspiration use was 64% and 9%, respectively, before training, an MVA workshop introduced the technique. Postabortion contraception was provided to 9%-29% of women, far below the target of 60%.

Regional collaborations as a way forward for maternal, newborn and child health: the South Asian healthcare professional workshop.

This article reviews the importance of regional initiatives in the context of global efforts to achieve the Millennium Development Goal 4 and 5 and describes the action-oriented multi-country healthcare professional association (HCPA) workshops organized by the Partnership for Maternal, Newborn and Child Health. The South Asian HCPA workshop served as a catalyst for strengthening the ability of HCPAs in South Asian countries to organize and coordinate their activities effectively, play a larger role in national planning, and collaborate with other key stakeholders in maternal, newborn and child health.

Dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban Pakistan.

OBJECTIVE: To compare the accuracy of the reported date of the last menstrual period (LMP) with that of symphysis-fundal height (SFH) in the estimation of gestational age (GA), using an ultrasound (US) scan as reference. METHODS: Gestational age was concurrently assessed by the 3 methods in this prospective, population-based, pregnancy-outcome study conducted in Hyderabad, Pakistan, from June 18, 2003, through August 31, 2005, with 1128 women between 20 and 26 weeks of a singleton pregnancy. RESULTS: The mean GA was less by ultrasound than by SFH measurement or the reported LMP, and the mean differences with the US result were statistically significant (P<0.001 for both). At delivery, about 75% of the GA values estimated by SFH measurement were within 7 days and almost 91% were within 14 days of the estimation by ultrasound, compared with 65% and 82% for the GA estimated by the reported LMP. Moreover, using the US as reference, the SFH correctly classified 84% of the term, 68% of the preterm, and 86% of the post-term deliveries (weighted kappa=0.58) compared with the corresponding 79%, 61%, and 55% predicted by the reported LMP (weighted kappa=0.44). CONCLUSION: The SFH measurement was found to be more accurate than the reported LMP as a tool to estimate GA and therefore date of delivery, but neither were as accurate as a US scan.

Prevention of unsafe abortion: analysis of the current situation and the task ahead.

An evaluation of the current situation regarding implementation of the plans of action for the prevention of unsafe abortion shows that more than half of the countries selected for the initiative have progressed as planned or have surpassed expectations. The greatest barriers to faster progress have been insufficient resources or infrastructure and the sensitivity of the subject matter, as well as lack of a more active commitment from the societies of obstetrics and gynecology and their members. The most frequently mentioned facilitating factors were the strength of the project/FIGO leadership, the commitment of the collaborating agencies, and incorporation of the activities of the plans of action into the agenda of the Ministry of Health. The commitment of the societies of obstetrics and gynecology and a good relationship between these societies and their Ministry of Health were also mentioned as being important facilitating factors. On the operational side, the monitoring visits and the regional workshops were seen as facilitators by over three-quarters and two-thirds of the countries, respectively. FIGO is committed to continue providing technical and political support to the societies involved in this initiative, promoting strategies to overcome the barriers while taking full advantage of the facilitating factors.

International organizations and NGOs: an example of international collaboration to improve women's health by preventing unsafe abortion.

International collaboration with organizations and agencies is a basic requirement for the success of the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences. Many activities being carried out by the organizations form a part of the plans of action of all countries participating in the Initiative. It was, therefore, not difficult to obtain their collaboration in implementing the plans of action. The many ways in which they have collaborated and continue to do so are described in this article. This collaboration has saved time, avoided duplication of effort, and has also satisfied the Accra Agenda of Action by reducing fragmentation of funding. It has already contributed toward preventing unsafe abortion and reducing abortion-related maternal deaths and morbidities, and is expected to contribute even more significantly in the coming months and years.

Addressing critical gaps in achieving universal access to sexual and reproductive health (SRH): the case for improving adolescent SRH, preventing unsafe abortion, and enhancing linkages between SRH and HIV interventions.

The new target for achieving universal access to reproductive health was integrated within the revised Millennium Development Goal framework in October 2008, following reaffirmation of this ICPD goal at the 2005 World Summit. To achieve this goal, the Alliance for Women's Health identified 3 issues needing urgent attention: (1) adolescent sexual and reproductive health; (2) unsafe abortions and related mortality and morbidity; and (3) HIV prevention and care. These themes were discussed in Cape Town at the FIGO 2009 Precongress Workshop convened by the Alliance. The critical gaps identified by the Workshop included: the lack of information on sexual and reproductive health (SRH) issues for adolescents, such as safe sexual practices, contraception, risks related to early childbearing; unsafe abortion and its adverse consequences; and inadequate linkages between sexual and reproductive health and HIV interventions that result in missed opportunities for addressing both. Recommendations included the use of innovative information dissemination techniques, ensuring access to family planning and comprehensive abortion care to the full extent allowed by national laws, in accordance with FIGO and WHO guidelines, and promotion of universal HIV counseling and testing with opt-out strategies within SRH services and information on SRH in all HIV services.

Sexual rights and gender roles in a religious context.

A common feature of the five faiths discussed in this article is change over time. This allowed diversity within the religions, and generally led to a degree of liberalization, but in some faiths or their sects, resulted in a narrow or rigid interpretation. For example, the golden Vedic Period of Hinduism in India when "women were worshipped" gradually faded, ushering in the social evils of female feticide, child marriage, and "sati." The advent of Islam in the seventh century banned female infanticide, but has been unable to abolish many tribal pre-Islamic customs such as female genital mutilation in Africa and "honor killings" in parts of Asia. On the other hand, in China, the inferior status of women accorded by Confucianism has been rectified to a large extent by legislation; this has, however, been offset by a restrictive population policy allowing only one child or two children per couple in some areas of the country (with no limit in Tibet), which has led millions of women to resort to prenatal sex diagnosis and abortion if the fetus is female. In the West, the debate over the use of biomedical technology continues, with various rabbinic rulings permitting the use of assisted reproductive technologies by Jews to fulfill the obligation to procreate, and the Vatican reinforcing its opposition to these and to genetic testing on embryos and embryonic stem cell research.

Sonographic foetal measurements in a cohort of population of Karachi, Pakistan.

The purpose of this cross-sectional study was to establish reference intervals for sonographic measurements of foetal parameters in women with normal singleton pregnancies in a cohort of population of Karachi, Pakistan. It was conducted at the Ultrasound Clinic, and Ziauddin Memorial Hospital, Nazimabad, Karachi, from January 2003 to July 2004. The measurements of foetal biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were carried out on commercially available ultrasound machines using a convex probe of 3.5 MHz frequency. Four hundred women were enrolled; 358 women completed the study. Mean +/- SD, reference intervals and 5th and 95th centiles for the foetal parameters were computed. Regression equations calculated were BPD = -0.36 + 0.27 x GA, (R2 = 0.97); HC = -0.96 + 0.05 x GA, (R2 = 0.95); AC = -0.345 + 0.33 x GA, (R2 = 0.95) and for FL = -1.50 + 0.24 x GA, (R2 = 0.97). [GA = gestational age in weeks, R2 = coefficient of determination]. In this cross-sectional study, predominantly of Urdu-speaking "mohajirs" (67.9%) the reference intervals of commonly used foetal parameters for assessing gestational age i.e. BPD, HC, AC and FL, were established. A larger, multi-centered study to encompass the different ethnic groups of the population is required.

Ovarian reserve and BMI between fertile and subfertile women.

OBJECTIVE: To compare the ovarian reserve and BMI in fertile and subfertile women aged 20-39 years by ultrasonography. STUDY DESIGN: A comparative study. PLACE AND DURATION OF STUDY: The Ultrasound Clinic, PECHS, Karachi, from March to December 2006. METHODOLOGY: Eighty women, 40 fertile and 40 subfertile, were subdivided into age groups of 20-29 and 30-39 years. Total ovarian volume (OV) was determined transabdominally (OV-TA) and transvaginally (OV-TV), antral follicle count (AFC) was performed transvaginally; and BMI was calculated. Unpaired t-test and Pearson correlation tests were used for analysis. RESULTS: In the total and subfertile females, aged 20-39 years, OV-TA obtained was 10.47 +3.81 ml vs. 7.0+2.67 (p=0.015), OV-TA was 12.55+4.53 ml vs. 8.36+2.36 ml (p=0.001); AFC was 7.35+3.02 vs. 5.7+3.57 (p=0.027) and BMI was 23.4+3.9 vs. 26.5+4.7 (p=0.006). In the older group of fertile and subfertile females, aged 30-39 years, OV-TA was 7.92+2.01 ml vs. 6.74+2.38 (p=0.097), OV-TA was 9.97+2.99 vs. 7.73+2.40 (p=0.012), AFC was 5.30+2.05 vs. 3.05+2.46 (p=0.003), and BMI was 24.4+3.8 vs. 27.4+4.80 (p=0.034). A significant negative correlation was present between ovarian volume and BMI in the older fertile women only (p=0.001 r=0.3) whereas no significant correlation was seen in the two parameters in any other group (r=0.1). CONCLUSION: The ovarian reserve decreased with increasing age. The lack of ovarian reserve may lead to subfertility or early ovarian ageing. Ovarian volume showed decrease with an increase in the BMI, indicating the possible decrease in fertility with an increase in a woman's weight.

The correlation between ultrasonic manual and automatic measurements of foetal head and abdominal circumferences.

OBJECTIVE: To assess the correlation between ultrasonic manual and automatic ellipsoid measurements of foetal head and abdominal circumferences. METHODS: This comparative cross-sectional study was conducted at the Ultrasound Clinic, Karachi, from January to July 2004. Seventy two normal pregnant women with gestational ages between 14 to 38 weeks were included. Foetal head and abdominal circumferences were measured by manual method using traditional formulae and by automatic ellipsoid mode incorporated into the real-time ultrasound machines (EcoCee and Power Vision, Toshiba, Japan) using convex probes of 3 and 4.2 MHz frequency. Three readings of each parameter i.e. head circumference (HC) and abdominal circumference (AC) were taken by both methods. Mean values were calculated and compared using paired sample 't' test to assess the correlation between ultrasonic manual and automatic ellipsoid measurements. RESULTS: The mean HC measured through manual method was found to be 20.11 +/- 7.04 cm and was significantly different from that of 19.46 +/- 6.82 cm measured through ellipsoid automatic technique. There was, however, a perfect positive correlation (r = 0.999) between these measurements. In case of AC, there was no statistical difference between the mean values obtained by the manual technique and those measured automatically (16.79 +/- 6.24 vs. 16.74 +/- 6.11; p < 0.44), correlation between these measurements (r = 0.997) was also significantly positive. CONCLUSION: Correlation was found between the mean measurements of the foetal HC and AC by the manual and the automatic method of calculation; and even stronger for the latter. The automatic mode of measurement is a more rapid method than the manual calculation, and its use may be encouraged.