The association between quality of contraceptive counseling and selection of contraceptive method post-counseling among women in Ethiopia.

OBJECTIVES: To better understand the relationship between high-quality contraceptive counseling and met family planning needs, we examined the association between quality of counseling and selection of a method postvisit among women requesting contraception in Ethiopia. STUDY DESIGN: We used post-counseling survey data from women receiving care in public health centers and nongovernmental clinics in three regions in Ethiopia. Among women whose reason for visit was requesting a contraceptive method, we examined the association between scores on the validated quality of contraceptive counseling (QCC) scale and subscales and selection of a method post-counseling (primary analysis) and type of method selected (secondary analysis). We conducted mixed-effects multivariable logistic regression for the primary analysis and multinomial regression for the secondary analysis. RESULTS: There was a nonsignificant increase in odds of selecting contraception with increasing total QCC scale scores (adjusted odds ratio [aOR] 2.35, 0.43-12.95). However, among women experiencing no disrespect and abuse, there was increasing odds of selecting contraception (aOR 3.46, 95% CI 1.09-10.99) and likelihood of selecting injectable contraception (adjusted relative risk ratio 4.27, 95% CI 1.34-13.60) compared to women experiencing disrespect and abuse. Additionally, 168 (32.1%) of women felt pressured by their provider to use a certain method of which>50% selected long-acting reversible contraception. CONCLUSIONS: Increasing QCC is associated with selecting contraception among women requesting contraception. Additionally, probing for negative experiences can reveal feelings of disrespect and abuse that could lead women to avoid selecting contraception or feeling pressured to use methods heavily promoted by providers. IMPLICATIONS: Our study assesses contraceptive counseling quality using a validated tool with items on provider pressure and other forms of disrespect and abuse; findings highlight the importance of respectful treatment in meeting women's needs and the potential influence of disrespect on decision to select contraception and type of method selected.

Systemic hormonal contraception initiation after abortion: A systematic review and meta-analysis.

BACKGROUND: Immediate contraceptive initiation, including start of a method before abortion completion, is a convenient option for women seeking abortion care. OBJECTIVES: To evaluate the effect of systemic hormonal contraception initiation on medical abortion effectiveness and the safety of hormonal contraceptive methods following abortion. DATA SOURCES: PubMed, Popline, Cochrane Library, and Clinicaltrials.gov. STUDY ELIGIBILITY CRITERIA: Studies that assessed medical abortion effectiveness after systemic hormonal contraception initiation and the safety of hormonal contraception initiation after abortion. PARTICIPANTS: Pregnant persons undergoing or who had recently undergone an abortion. INTERVENTIONS: Initiation of systemic hormonal contraception post abortion or on the day of the first pill of the medical abortion. STUDY APPRAISAL AND SYNTHESIS METHODS: We assessed study quality using the US Preventive Services Task Force evidence grading system. We created narrative summaries and calculated pooled relative risks when appropriate. RESULTS: We identified 16 studies for inclusion, 7 randomized controlled trials, and 9 cohorts. Nine studies assessed medical abortion effectiveness with hormonal contraception initiation and generally found no decreased risk of abortion success or increased risk of additional treatment. One fair-quality study reported a small increase in ongoing pregnancy rate with immediate depot medroxyprogesterone (DMPA) compared with delayed DMPA initiation (3.6% vs 0.9%, risk difference 2.7%, 90% confidence interval 0.4-5.6). We identified no bleeding-related safety concerns following hormonal contraception initiation after medical or surgical abortion. Pooled results were too imprecise to draw firm conclusions. LIMITATIONS: Included studies were poor or fair quality and primarily in high-income or upper-middle-income settings. CONCLUSIONS: Abortion effectiveness did not differ between immediate vs delayed initiation of most systemic hormonal contraceptive methods after a first trimester medical abortion. However, immediate DMPA initiation did show increased ongoing pregnancy. Bleeding effects with hormonal contraception initiation postabortion appeared minimal. IMPLICATIONS: Initiating a hormonal contraceptive method after an abortion and as early as the same day as the first pill of the medical abortion is an option if contraception is desired. The slight increase in ongoing pregnancy with immediate DMPA initiation highlights the importance of information provision during contraceptive counseling.

Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis.

OBJECTIVES: To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States. DATA SOURCES: We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019. STUDY ELIGIBILITY CRITERIA: We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion. STUDY APPRAISAL AND SYNTHESIS METHODS: We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression. RESULTS: We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65). CONCLUSION: Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.

Health Care Provider Attitudes Toward Safety of Selected Hormonal Contraceptives in Breastfeeding Women.

OBJECTIVES: Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women. METHODS: Using a nationwide survey, associations were analyzed between provider characteristics and perception of safety of combined oral contraceptives (COCs) in breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors and depot medroxyprogesterone acetate (DMPA) in breastfeeding women < 1 month postpartum and ≥ 1 month postpartum. RESULTS: Approximately 68% of public-sector providers considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among non-physicians versus physicians (adjusted odds ratios [aOR] range 0.34-0.51) and those with a focus on adolescent health/pediatrics versus reproductive health (aOR 0.68, 95% confidence interval [CI] 0.47-0.99). Most public-sector providers considered DMPA safe for breastfeeding women during any time postpartum, with lower odds among non-physicians versus physicians (aOR range 0.20-0.54) and those with primary clinical focus other than reproductive health (aOR range 0.26-0.65). The majority of office-based physicians considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among those who did not use, versus those who used, CDC's contraceptive guidance (aOR 0.40, 95% CI 0.21-0.77). Most office-based physicians also considered DMPA safe for breastfeeding women during any time postpartum. CONCLUSIONS FOR PRACTICE: A high proportion of providers considered use of selected hormonal contraceptives safe for breastfeeding women, consistent with evidence-based guidelines. However, certain provider groups might benefit from education regarding the safety of these methods for breastfeeding women.

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis.

PURPOSE: To evaluate the accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis (ARS). METHODS: We searched Medline to identify studies of outpatients with clinically suspected ARS and sufficient data reported to calculate the sensitivity and specificity. Of 1,649 studies initially identified, 17 met our inclusion criteria. Acute rhinosinusitis was diagnosed by any valid reference standard, whereas acute bacterial rhinosinusitis (ABRS) was diagnosed by purulence on antral puncture or positive bacterial culture. We used bivariate meta-analysis to calculate summary estimates of test accuracy. RESULTS: Among patients with clinically suspected ARS, the prevalence of imaging confirmed ARS is 51% and ABRS is 31%. Clinical findings that best rule in ARS are purulent secretions in the middle meatus (positive likelihood ratio [LR+] 3.2) and the overall clinical impression (LR+ 3.0). The findings that best rule out ARS are the overall clinical impression (negative likelihood ratio [LR-] 0.37), normal transillumination (LR- 0.55), the absence of preceding respiratory tract infection (LR- 0.48), any nasal discharge (LR- 0.49), and purulent nasal discharge (LR- 0.54). Based on limited data, the overall clinical impression (LR+ 3.8, LR- 0.34), cacosmia (fetid odor on the breath) (LR+ 4.3, LR- 0.86) and pain in the teeth (LR+ 2.0, LR- 0.77) are the best predictors of ABRS. While several clinical decision rules have been proposed, none have been prospectively validated. CONCLUSIONS: Among patients with clinically suspected ARS, only about one-third have ABRS. The overall clinical impression, cacosmia, and pain in the teeth are the best predictors of ABRS. Clinical decision rules, including those incorporating C-reactive protein, and use of urine dipsticks are promising, but require prospective validation.

Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents.

PURPOSE: Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents. METHODS: We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year. RESULTS: The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20). CONCLUSIONS: While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.

Zika Virus RNA Replication and Persistence in Brain and Placental Tissue.

Zika virus is causally linked with congenital microcephaly and may be associated with pregnancy loss. However, the mechanisms of Zika virus intrauterine transmission and replication and its tropism and persistence in tissues are poorly understood. We tested tissues from 52 case-patients: 8 infants with microcephaly who died and 44 women suspected of being infected with Zika virus during pregnancy. By reverse transcription PCR, tissues from 32 (62%) case-patients (brains from 8 infants with microcephaly and placental/fetal tissues from 24 women) were positive for Zika virus. In situ hybridization localized replicative Zika virus RNA in brains of 7 infants and in placentas of 9 women who had pregnancy losses during the first or second trimester. These findings demonstrate that Zika virus replicates and persists in fetal brains and placentas, providing direct evidence of its association with microcephaly. Tissue-based reverse transcription PCR extends the time frame of Zika virus detection in congenital and pregnancy-associated infections.

Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy.

BACKGROUND: Acute rhinosinusitis (ARS) is a common primary care infection, but there have been no recent, comprehensive diagnostic meta-analyses. AIM: To determine the accuracy of laboratory and imaging studies for the diagnosis of ARS. DESIGN AND SETTING: Systematic review of diagnostic tests in outpatient, primary care, and specialty settings. METHOD: The authors included studies of patients presenting with or referred for suspected ARS, and used bivariate meta-analysis to calculate summary estimates of test accuracy and the area under the receiver operating characteristic (ROC) curve. The authors also plotted summary ROC curves to explore heterogeneity, cutoffs, and the impact of different reference standards. RESULTS: Using antral puncture as the reference standard, A mode ultrasound (positive likelihood ratio [LR+] 1.71, negative likelihood ratio [LR-] 0.41), B mode ultrasound (LR+ 1.64, LR- 0.69), and radiography (LR+ 2.01, LR- 0.28) had only modest accuracy. Accuracy was higher using imaging as the reference standard for both ultrasound (LR+12.4, LR- 0.35) and radiography (LR+ 9.4, LR- 0.27), although this likely overestimates accuracy. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) both had clear threshold effects, and modest overall accuracy. The LR+ for ESR >30 and >40 were 4.08 and 7.40, respectively. A dipstick of nasal secretions for leucocyte esterase was highly accurate (LR+ 18.4, LR- 0.17) but has not been validated. CONCLUSION: In general, tests were of limited value in the diagnosis of ARS. Normal radiography helps rule out sinusitis when negative, whereas CRP and ESR help rule in sinusitis when positive, although, given their limited accuracy as individual tests, they cannot be routinely recommended. Prospective studies integrating signs and symptoms with point-of-care CRP, dipstick, and/ or handheld B-mode ultrasound are needed.

Pathology of congenital Zika syndrome in Brazil: a case series.

BACKGROUND: Zika virus is an arthropod-borne virus that is a member of the family Flaviviridae transmitted mainly by mosquitoes of the genus Aedes. Although usually asymptomatic, infection can result in a mild and self-limiting illness characterised by fever, rash, arthralgia, and conjunctivitis. An increase in the number of children born with microcephaly was noted in 2015 in regions of Brazil with high transmission of Zika virus. More recently, evidence has been accumulating supporting a link between Zika virus and microcephaly. Here, we describe findings from three fatal cases and two spontaneous abortions associated with Zika virus infection. METHODS: In this case series, formalin-fixed paraffin-embedded tissue samples from five cases, including two newborn babies with microcephaly and severe arthrogryposis who died shortly after birth, one 2-month-old baby, and two placentas from spontaneous abortions, from Brazil were submitted to the Infectious Diseases Pathology Branch at the US Centers for Disease Control and Prevention (Atlanta, GA, USA) between December, 2015, and March, 2016. Specimens were assessed by histopathological examination, immunohistochemical assays using a mouse anti-Zika virus antibody, and RT-PCR assays targeting the NS5 and envelope genes. Amplicons of RT-PCR positive cases were sequenced for characterisation of strains. FINDINGS: Viral antigens were localised to glial cells and neurons and associated with microcalcifications in all three fatal cases with microcephaly. Antigens were also seen in chorionic villi of one of the first trimester placentas. Tissues from all five cases were positive for Zika virus RNA by RT-PCR, and sequence analyses showed highest identities with Zika virus strains isolated from Brazil during 2015. INTERPRETATION: These findings provide strong evidence of a link between Zika virus infection and different congenital central nervous system malformations, including microcephaly as well as arthrogryposis and spontaneous abortions. FUNDING: None.