Improving contraceptive care for minors in Israel: practice, policy, and training gaps among OBGYNs.

BACKGROUND: Sexually active adolescents sometimes seek contraceptives without parental consent, posing challenges due to minors' confidentiality and consent regulations. This is especially the case under the un-nuanced Israeli legal scheme regarding adolescents' care. METHODS: Israeli OBGYNs were contacted through mailing lists and social media groups and asked to fill an online questionnaire regarding their experience and protocols concerning prescription of contraceptives to minors. They were also asked about their comprehension of the relevant legal obligations, the importance they ascribe to different ethical interests and considerations, as well as their training. RESULTS: Of the 177 responding gynecologists, 132 (74.58%) consulted minors about contraceptives during the past year, regardless of a vast lack of training on providing care to minors. More than a third of respondents believed that there is no legal requirement to involve parents in the process, and only 8% assumed a legal obligation for parental involvement in all minors under the age of 18. Three quarters would "almost always" prescribe contraceptives without parental knowledge, if requested, while 20% never would. No correlation was found between respondents' practices and their perception of the relevant legal obligations. Participants agreed that the risk to the health of the minor as a result of having sex without contraceptives is of utmost importance. Yet, those willing to prescribe gave greater weight to this consideration, while those who do not prescribe were more concerned with the legal ramifications of such an act. The majority identified the age of 15 as the threshold for consistently prescribing contraceptives to minors without parental involvement. CONCLUSION: This study highlights the significant gaps in both the legal framework and the training of Israeli OBGYNs, and further supports confidential prescription of contraceptives to minors 15 years and older, via Article 6 of the Israeli Legal Competence and Guardianship Law. Legislative reform, professional guidelines and education and training programs are all needed to ensure consistent and legally sound practices, that safeguard the health and rights of minors. It is imperative to guide healthcare providers, including OBGYNs prescribing contraceptives to minors, on managing the care of minors refusing parental involvement, clarifying the legal framework and ethical considerations involved.

[PRESCRIBING CONTRACEPTIVES TO MINORS WITHOUT PARENTAL CONSENT].

INTRODUCTION: The Israeli Legal Capacity and Guardianship Law, denies minors the right to decide upon medical treatment, and regards medical treatment of minors, including contraception, without parental consent as an infringement of parental autonomy. Yet, adolescent girls occasionally ask doctors to prescribe them contraceptives, while refusing parental involvement. This article reviews the relevant legal situation, examines some comparative legal stances and refers to the ethical aspects that should be considered during contraceptive advice to minors, in light of the United Nations Convention on the Rights of the Child. Seeking contraception is an example of mature behaviour, and when a minor asks for contraception, the physician has to act in her best interests. In the decision to prescribe contraceptives without parental consent or even knowledge, doctors should consider the girl's ability to understand their advice, the risks associated with lack of parental involvement, the significance of parental autonomy infringement, the risks to the girl if the parents will be informed contrary to her request, and the girl's risks of unintended pregnancy, associated with not using contraception. In this article we suggest means and modes of action in a situation when an adolescent needs contraception and denies any parental involvement.

Urinary incontinence in physically active women and female athletes.

A literature review was performed on the topic of urinary incontinence during physical activity and sports. This paper reviews the prevalence, risk factors, pathophysiology and treatment modalities of urinary incontinence in physically active women and female athletes. Urinary incontinence affects women of all ages, including top female athletes, but is often under-reported. The highest prevalence of urinary incontinence is reported in those participating in high impact sports. Pelvic floor muscle training is considered the first-line treatment, although more research is needed to determine optimal treatment protocols for exercising women and athletes. Trainers, coaches and other athletes' caregivers should be educated and made aware of the need for proper urogynaecological assessment.

Characteristics of attachment style in women with dyspareunia.

In this study, the authors explored the relations among painful experience during sexual intercourse, attachment style, and somatization. The authors assessed these variables by self-report of dyspareunia (painful vaginal intercourse) and by completion of the Experience in Close Relationships Scale and the short version of the Brief Symptom Inventory. The sample included 110 women, 45 of whom reported painful intercourse and were defined as the dyspareunia group, and the remaining 65 were defined as the control group. The dyspareunia group showed greater incidence, compared with the control group, of insecure attachment styles defined by higher scores of anxiety and/or avoidance as well as higher somatization levels. Regression analyses revealed that increased level of somatization and higher level of avoidance predicted higher probability for dyspareunia. The authors' findings suggest that women with higher frequency of physical complaints in various body areas and insecure attachment style are more susceptible to report pain during intercourse.

Intrapartum prophylaxis of group B streptococcal disease in Israel: guidelines and practice.

BACKGROUND: The incidence of perinatal, early-onset Group B streptococcal sepsis is very low in Israel and there are no local guidelines for prevention of the disease. OBJECTIVES: To determine to what extent the current Centers for Disease Control guidelines are practiced in Israel, the reasons for their adoption or rejection, and the need for local official guidelines. METHODS: A telephone questionnaire was conducted of all 27 delivery units in Israel. Answers were obtained from 26, either from the clinical director or the senior obstetrician in charge at the time of the interview. RESULTS: Only in 2 of the 26 delivery units (8%) are the CDC guidelines adhered to exactly; in 6 units they are deliberately rejected, and in 8 units they are not practiced although they are allegedly implemented. Thus, the CDC guidelines are not practiced in 14 delivery units (54%). Medico-legal consideration is the sole or major reason for adopting these guidelines in 80% (16/20) of the delivery units where they are seemingly implemented. In the majority of these units (18/20) there is readiness to abandon current practice, should local guidelines differ from those of the CDC, provided that local guidelines are issued by an authoritative source. CONCLUSION: CDC guidelines are either deliberately rejected or incorrectly practiced in most Israeli delivery units. The medico-legal argument is one of the main reasons for practicing these guidelines. Since the CDC guidelines probably do not apply in Israel, official local guidelines are urgently needed.

Computerized analysis of fetal heart rate indices during oral glucose tolerance test.

AIMS: To study the effect of maternal glucose ingestion during a 100 g oral glucose tolerance test on fetal heart rate indices. STUDY DESIGN: Prospective study including 50 pregnant patients with an abnormal glucose challenge test who underwent a 100 g glucose tolerance test at 26-28 weeks gestation. Fetal heart rate was recorded and analyzed with the computerized Sonicaid Fetal Monitor System (Oxford 8000). RESULTS: Baseline fetal heart rate significantly increased 120 and 180 minutes following glucose ingestion (p < 0.05) both in patients who were subsequently diagnosed to have gestational diabetes and in these in whom the diagnosis was excluded. No significant changes were noted in other fetal heart indices. CONCLUSIONS: The significant and consistent increase in baseline fetal heart rate following maternal glucose ingestion indicates that the fetus responds to changes in its' environment. The exact mechanism which causes this response has yet to be defined.

The circadian rhythm of "urgent" operative deliveries.

BACKGROUND: Even operative deliveries defined as "urgent" show marked diurnal variation with a significant increase during regular working hours. OBJECTIVE: To investigate the diurnal variation of urgent operative deliveries and its potential implications on the outcome of newborns. METHODS: We conducted a retrospective study of all deliveries in a public hospital from 1 January 1990 to 31 December 1998. Delivery mode variables analyzed were spontaneous vaginal delivery, urgent cesarean section and operative vaginal delivery. Deliveries were stratified hourly throughout the day. The rate of operative deliveries was calculated and the analysis was then performed according to the daily routine shifts of the medical staff. Birth weight and Apgar scores at 1 and 5 minutes were retrieved as outcome measures. RESULTS: The rate of urgent cesarean deliveries increased significantly between 8 a.m. and 2 p.m. (150%-230%) from that predicted. The lowest rate of urgent cesarean sections was found between 5 a.m. and 6 a.m. (5.3%). Mean birth weight in spontaneous deliveries was higher in the morning hours than during the night shift (3,293 +/- 520 g vs. 3,277 +/- 510 g, respectively, P < 0.005). Apgar scores of newborns delivered by urgent cesarean section during the morning were higher compared to those delivered during night shifts and the rate of low Apgar scores was lower in the morning than in evening and night shifts. CONCLUSIONS: Our results indicate a marked diurnal variation in urgent operative deliveries, caused perhaps by varying definition of "urgency" according to the time of day.