A comparison of triage methods for Kenyan women who screen positive for cervical intraepithelial neoplasia by visual inspection of the cervix with acetic acid.

BACKGROUND: Only about one in seven visual inspection with acetic acid (VIA)-positive women has high-grade disease; further confirmatory testing could rule out false positives. OBJECTIVES: To determine if visual inspection with Lugol's iodine (VILI) or visual inspection with acetic acid and magnification (VIAM) can accurately confirm the presence of disease among rural Kenyan women referred to a district hospital because of a VIA-positive result at a primary health facility. METHODS: Referred women received cervical cytology and either VILI and/or VIAM as triage methods. All women were assessed by colposcopy and biopsied, if necessary. RESULTS: Of the 490 VIA-positive subjects referred, 332 (68%) attended the district hospital and received at least one of two triage tests and cervical cytology. The sensitivity and specificity for histologically-confirmed CIN 2 and 3 were 93% (14/15) and 32% (52/161) for VIAM; 100% (3/3) and 77% (49/64) for VILI; and 80% (16/20) and 48% (110/228) for cervical cytology. VILI reduced the number of false-positive screening results by 73%, without missing any true positives. CONCLUSIONS: VILI had comparable sensitivity and significantly higher specificity compared to VIAM and cervical cytology. VILI may be a promising triage test for screen-positive women in low-resource settings; additional research is required.

Report on a cryotherapy service for women with cervical intraepithelial neoplasia in a district hospital in western Kenya.

BACKGROUND: In low-resource settings, cryotherapy can be cost-effective, affordable, and a first-line treatment for cervical intraepithelial neplasia (CIN) of any grade. OBJECTIVES: To report the acceptability, safety and effectiveness of cryotherapy for women with cervical intraepithelial neoplasia (CIN) in Western Kenya. METHODS: Visual inspection with acetic acid (VIA)-positive women and those suspected of having cervical cancer based on an initial evaluation at a primary health facility were referred to the district hospital for colposcopy and additional evaluation using visual inspection with Lugol's iodine (VILI) and/or visual inspection with acetic acid and magnification (VIAM). Cryotherapy was offered immediately to women diagnosed with appropriate CIN lesions based on colposcopy or after waiting for a confirmatory cervical biopsy and a follow up visit occurred one year later. RESULTS: Ninety one 91 women 30 to 39 years of age had CIN appropriate for cryotherapy. Approximately 36% (24/67) were due for their 1 year follow up visit and 20 of 24 (83.3%) attended. Complete data were available for 18 of 20 (90%) and 13 (72.2%) had no sign of CIN. No serious adverse events were reported 1 to 3 months after cryotherapy. All respondents reported that the treatment experience was acceptable. CONCLUSIONS: Cryotherapy was acceptable, safe and effective.

New and underutilised technologies to reduce maternal mortality and morbidity: what progress have we made since Bellagio 2003?

In 2003, maternal health experts met in Bellagio, to consider new and underutilised technologies vital to pregnancy-related health services in low-resource settings. Five years later, we examine what progress has been made and what new opportunities may be on the horizon. Based on a review of literature and consultation with experts, we consider technologies addressing the five leading causes of maternal mortality: postpartum haemorrhage, eclampsia, obstructed labour, puerperal sepsis, and unsafe abortion (pregnancy termination and miscarriage). In addition, we consider technologies related to obstetric fistula, which has received more attention in recent years.

Preventing cervical cancer in low-resource settings: how far have we come and what does the future hold?

The Alliance for Cervical Cancer Prevention (ACCP) came together in 1999 to answer key research questions and to advocate for greater global and national interest in reducing the heavy burden of morbidity and mortality caused by this preventable disease. Visual inspection with acetic acid (VIA), visual inspection with Lugol's iodine (VILI), and human papillomavirus (HPV) tests have been shown to be viable alternatives to traditional cytology. ACCP experience confirmed that cryotherapy is a safe and effective method that is acceptable to women and can be delivered by a range of health providers, including nonphysicians. Programs can maximize coverage by accommodating local needs and involving community leaders and women in planning and implementation. Advocacy efforts have led to significant policy changes and galvanized support for cervical cancer prevention. Despite the prospect of new HPV vaccines, screening will be needed for at least the next 30-40 years. Our experience has shown that with creativity, flexibility, and well-focused use of resources, the inequitable burden of cervical cancer borne by women in poor countries can be sharply reduced.

Postpartum hemorrhage in developing countries: is the public health community using the right tools?

OBJECTIVES: To identify new and underutilized technologies that may assist in reducing maternal mortality due to obstetric hemorrhage. METHODS: Review of published and unpublished literature, including systematic reviews of randomized trials and individual clinical studies. RESULTS: Hemorrhage, primarily postpartum, accounts for approximately 25% of maternal deaths globally. Uterotonic drugs offer great promise for both prevention and management of postpartum hemorrhage (PPH). Other technologies--such as anti-shock garments, umbilical vein injection of oxytocin, and simple anemia detection methods--represent potential new opportunities to reduce PPH-related mortality. CONCLUSIONS: Clinical and operational research is needed to answer remaining questions about misoprostol, the anti-shock garment, and umbilical vein injection of oxytocin for retained placenta. Efforts are needed to ensure the availability of technologies with proven value, such as oxytocin in Uniject prefilled injection devices. Equally important, technologies and techniques with proven efficacy--such as active management of third-stage labor and aortic compression--must be translated into general use by disseminating the evidence for them, incorporating them into national guidelines and training curricula, and ensuring the availability of supportive supplies and equipment.

New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop.

Little progress has been made in preventing the more than 500,000 maternal deaths that occur each year. Many new and underutilized technologies can be used to reduce these deaths. In July 2003, maternal health experts from around the world gathered in Bellagio, Italy, to develop a set of priority actions for reducing maternal mortality using proven and promising technologies. To reduce maternal mortality, immediate efforts are needed to accelerate the appropriate use of technologies and to reduce their inequitable distribution. Organizations are called on to commit the necessary human and financial resources to evaluate and document the effectiveness of promising technologies and to scale up and put proven technologies into widespread use to save women's lives.

Oxytocin in prefilled Uniject injection devices for managing third-stage labor in Indonesia.

We assessed the use and acceptability of an injection device (Uniject) prefilled with oxytocin, as part of active management of third-stage labor (AMTL) by Indonesian midwives attending home births. We interviewed 140 village midwives (bidan di desa) and 2220 mothers whose deliveries they attended during the intervention period. We completed baseline and post-intervention assessments to determine their experiences and views of oxytocin Uniject use. Delivery logs and supervisory reports were reviewed. The assessment was done in three rural districts and one municipality in Lombok. Injection practices and oxytocin availability did not change dramatically, although dose accuracy, use of sterile injection equipment, and proper disposal improved when the Uniject device was used. Midwives had little difficulty using the Uniject device properly; they overwhelmingly preferred it to standard needles and syringes. Postpartum hemorrhage rates did not change substantially. Oxytocin via Uniject holds promise for safer, more convenient use of oxytocin by trained midwives attending home deliveries, thereby potentially reducing the incidence of postpartum hemorrhage.

Confirmation of cervical neoplasia using a hand-held, lighted magnification device.

OBJECTIVES: The objective of this study was to estimate the sensitivity and specificity of visual inspection with acetic acid and magnification (VIAM) using the AviScope device to confirm high-grade cervical intraepithelial neoplasia or carcinoma. METHODS: VIAM was performed on 142 women aged 18-50 years referred to three colposcopy clinics because of abnormal cervical cytology. Each woman then had a colposcopic examination with cervical biopsy when indicated. RESULTS: The AviScope device identified 24 of the 40 women who had CIN 2, 3, or carcinoma, yielding a sensitivity of 60.0% (95% CI 43.4, 74.7). The AviScope correctly identified 60 of 87 women negative for dysplasia or cancer, yielding a specificity of 69.0% (95% CI 58.0, 78.2) compared with colposcopy and cervical histology. CONCLUSION: VIAM using the AviScope device was moderately sensitive and specific for the confirmation of high-grade cervical lesions in women referred with abnormal cervical cytology.

Cervical dysplasia treatment: key issues for developing countries.

Many developing countries face serious obstacles that have hindered establishment of successful cervical cancer control programs. Various countries are now seeking to strengthen cytology services and identify simple low-cost screening strategies; but any real gains in reducing cervical cancer incidence and mortality will also require effective treatment of women with preinvasive disease. Despite a trend toward conservative outpatient approaches for treating cervical dysplasia in industrialized countries, clinicians in many developing countries still rely primarily on invasive inpatient methods such as cone biopsy and hysterectomy. For women who could be treated with less invasive methods, these procedures tend to pose unnecessary risks and entail high costs that put them beyond the reach of many patients. Outpatient therapy, employing methods such as cryotherapy and the loop electrosurgical excision procedure (LEEP), combined with proper follow-up, is appropriate for dealing with visible lesions on the ectocervix when invasive cancer and endocervical involvement have been ruled out. Cryotherapy and LEEP hold out particular promise for developing countries because of their effectiveness, lack of side-effects, simplicity, and low cost. Cure rates range from 80% to 95%, depending on the method used and the severity of the lesions. However, each method has advantages and disadvantages that demand consideration. Various ways of reducing the number of follow-up visits, including the two-visit "see and treat" approach, are also available for use in areas where women's access to health services may be limited. A recent survey by the Program for Appropriate Technology in Health (PATH) affirmed the tendency to rely on cone biopsy and hysterectomy. It also found that in many places all degrees of preinvasive disease were treated, rather than only high-grade or severe conditions; that respondents in Latin America, the Caribbean, and Asia tended to use cryotherapy and LEEP more widely than other low-cost methods; that LEEP was preferred over cryotherapy in Latin America; and that colposcopes and other basic equipment needed to provide treatment were not consistently or widely available in some settings.

PIP: Financial, technical, and logistical factors have impeded the establishment of effective cervical cancer control programs in many developing countries. Efforts are now underway to strengthen cytology services and identify simple, inexpensive, alternative screening strategies that will improve early detection of cervical intraepithelial neoplasia (CIN). As part of this effort, the Program for Appropriate Technology in Health (PATH) surveyed the CIN treatment practices and preferences of 110 health practitioners from 33 developing countries. The survey revealed widespread reliance on invasive inpatient procedures such as cone biopsy and hysterectomy and a tendency to treat all preinvasive CIN, rather than only high-grade or severe CIN. Simple, low-cost, effective (80-95%) outpatient procedures such as cryotherapy and the loop electrosurgical excision procedure (LEEP) were selected more widely in Asia, the Caribbean, and Latin America than in Africa, but remained underutilized relative to inpatient treatments. In many settings, colposcopes and other basic equipment were not available. Respondents identified hysterectomy, cone biopsy, and LEEP as the most effective treatments of severe dysplasia. Overall, these findings suggest a need for more efficient use of scarce medical resources. Cryotherapy and LEEP, combined with proper follow-up, are particularly appropriate for developing countries in cases where invasive cancer and endocervical involvement have been ruled out.

Antenatal screening: its use in assessing obstetric risk factors in Zimbabwe.

STUDY OBJECTIVE: To assess the predictive utility of obstetric risk factors for identifying before the onset of labour those women at high risk of obstetric complications in a developing world setting, where home deliveries predominate and emergency transport is scarce. DESIGN: Risk factors derived from two population based, case-control studies (one of cephalopelvic disproportion and one of post partum haemorrhage), carried out in Zimbabwe were used to construct weighted and unweighted scores, a variety of screening algorithms, and sets of probabilities estimated from logistic regression models. These screening tests were evaluated for sensitivity, specificity, positive predictive value, and "cost" (the proportion of the population testing positive). Each complication was evaluated separately and the two were then pooled. PARTICIPANTS: All were Harare residents with singleton, vertex deliveries and spontaneous onset of labour. A total of 201 experienced cephalopelvic disproportion, 150 had post partum haemorrhage, and 299 had normal, unassisted deliveries. MEASUREMENTS AND MAIN RESULTS: Largely because of the very low incidence of the two complications studied (1% or less), positive predictive values were low (less than 7%). Holding "cost" constant at 10%, a screening test for cephalopelvic disproportion could predict 42.3% of cases compared with only 35.0% of those with post partum haemorrhage. Weighted scores had little advantage over unweighted ones, and probabilities from the logistic regression models did not differentiate cases from controls very well. CONCLUSIONS: With simple algorithms based on maternal height, parity, and obstetric history, more than one third of women at risk for potentially fatal complications could be identified at relatively small cost to themselves or the health care system.

Postpartum haemorrhage in Zimbabwe: a risk factor analysis.

OBJECTIVES: To identify risk factors associated with postpartum haemorrhage (PPH) in order to improve the effectiveness of antenatal screening. DESIGN: A population-based case control study. SETTING: Harare, Zimbabwe. SUBJECTS: Two groups of women, one group consisting of those with postpartum haemorrhage after a normal vaginal delivery and the other of women with normal unassisted vaginal delivery without PPH. METHOD: Data abstracted from the medical records; relative risks were estimated by multivariate logistic regression. RESULTS: Low parity, advanced maternal age, and antenatal hospitalisation were among the strongest risk factors, with more modest associations for history of poor maternal or perinatal outcomes and borderline anaemia at the time of booking. No association with grand multiparity was found. CONCLUSIONS: These findings confirm the importance of previously recognised factors such as low parity, poor obstetric history, anaemia, and prolonged labour, but call into question the significance of grand multiparity. Previously undocumented factors such as maternal age greater than 35 years and occiput posterior head position emerged as predictors worthy of further investigation.

PIP: For both cases and controls, only singleton, vertex births with spontaneous onset of labor without oxytocic or instrumental intervention during delivery between May 1 and December 31, 1989, were included, and all eligible mothers were residents of Greater Harare. There were 2 case groups: women with postpartum hemorrhage after a normal vaginal delivery, and women with cephalopelvic disproportion (CPD) requiring surgical or instrumental delivery. Postpartum hemorrhage (PPH) was defined as excess bleeding with a minimum of 600 ml rather than 500 ml. Data were abstracted from the medical records. 2 control groups (PPH and CPD) were combined for a control group of 299 normal deliveries. Cases were much more likely than controls to have a traumatic delivery involving vaginal or cervical tears, which accounted for more than one-third of the hemorrhages. Uterine atony was the most common cause of PPH. There was one maternal death among the cases (case fatality rate of 6.6/1000). The perinatal mortality among the cases was 33.8/1000 live births (3 stillbirths, 2 neonatal deaths) and none among controls. Although cases and controls had similar mean gravidity (3.3) and parity (2.2), cases were more likely to have had either none or 1 previous delivery. Cases also had a higher proportion of grand multiparas (5 or more previous deliveries). More cases than controls reported outcomes such as PPH, miscarriage in the first or second trimester, or neonatal death. The results of the logistic regression analysis showed that women 35 years or more at delivery were at 2.5 times greater risk of PPH than were younger women. Women who were hospitalized antenatally for a pregnancy-related problem were at 3-4 times greater risk of PPH than were women without hospitalization. Occiput transverse or posterior fetal head position was associated with a nearly/10-fold greater relative risk for PPH.

Maternal height and age: risk factors for cephalopelvic disproportion in Zimbabwe.

Maternal age and stature are among several factors used to screen pregnant women for potential risk of labour complications. In a population-based case-control study in Harare, Zimbabwe, multivariate analysis was carried out to evaluate the importance of maternal age and height as risk factors for cephalopelvic disproportion (CPD). Using data abstracted from the medical records of 203 women with operative deliveries due to CPD and 299 women with normal unassisted vaginal deliveries, multiple logistic regression models were developed. Although maternal age < 18 years was not a significant risk factor in this study (perhaps because there were few women in this age group), advanced maternal age (> or = 35 years) was associated with a relative risk of 2.7 compared to women 20-34, after adjusting for other demographic and obstetric factors. Maternal height < 160 cm was associated with a twofold increased risk of CPD as compared to taller women.

PIP: In the Greater Harare area of Zimbabwe, a researcher compared data on 203 women who suffered from cephalopelvic disproportion (CPD) and underwent a cesarean section with data on 299 facility matched controls to determine the effects of maternal height and age and their significance for CPD. All the women delivered either at the municipal hospital or its clinics. When the researcher controlled for parity, young age (20 years) was not a risk factor. There were few 20-year old women, however. 35-year old mothers were at 2.1 times the risk for CPD than were 20.34 year olds after controlling for parity and at 2.7 times the risk after controlling for demographic and other obstetric factors. Women at a height of 160 cm had a relative risk for CPD of twice that of women at a height of 160 cm. Potential biases in this study included the possibility that women with prior cesarean section were underrepresented especially if they were selected for cesarean section for their short stature and questionable quality of the data in the medical records. This study was the 1st to document advanced maternal age as a risk factor for CPD but did not verify maternal youth as a risk factor. These results suggested that, even though short stature is a risk factor for CPD, there is a need to determine local cutoff points for screening purposes. Screening for CPD risk factors can reduce the likelihood of mothers having to endure prolonged labor.

Underutilization of health centers in rural Mexico: a qualitative approach to evaluation and planning.

PIP: A short field study of Durango, Mexico, is reported as a case study of a qualitative approach to evaluation. This approach uses a combination of methods, including in depth interviews, questionnaires, and participant/observation, to achieve a deeper understanding of program functioning and to provide a perspective unavailable from traditional quantitative measures. Recommendations for additional training for auxiliary nurses are offered.^ieng