Fertility desires and sexual behaviours among women recovering from genital fistula repair in Eldoret, Kenya.

OBJECTIVES: The reproductive desire of women following genital fistula repair surgery is complex, varied and often not addressed, although it carries significant consequences. The aim of this study was to better understand the fertility desires and sexual behaviours of women who recently underwent surgical repair of a genital fistula. METHODS: This is a secondary analysis of a retrospective cohort study designed to assess the effectiveness of Beyond Fistula, a reintegration programme for women recovering from genital fistula surgery in Eldoret, Kenya. One hundred women who participated in the Beyond Fistula programme between 2013 and 2019 were interviewed in person regarding future fertility desire, current sexual behaviour and contraceptive use. RESULTS: Among the 79 reproductive-aged women included in this study, 63.3% reported no future desire for pregnancy. Those that desired another pregnancy were significantly younger (48.3% were 18-29 years old vs. 66.0% were 35 years old or more, p = 0.004), had fewer living children (70% had 0-2 children vs. 56% had 3 or more children, p < 0.001), and a lower level of food insecurity (27.6% reported no to marginal insecurity vs. 14%, p = 0.014). Current sexual activity was marginally different between women who did and did not desire future pregnancy (82.8% vs. 66.0%, p = 0.053). Of the 50 women in our study who did not desire pregnancy, 62.0% were sexually active and of these, only 38.7% were preventing pregnancy. Lack of knowledge and access to methods were most commonly cited as barriers to use. CONCLUSIONS: Many women recovering from genital fistula surgery do not desire pregnancy and are sexually active but are not using a method to prevent pregnancy. The potential for post-surgical reintegration programmes to address education and access to contraception is a vital and unmet need to promote reproductive empowerment in this population of women as they reestablish their lives.

Doulas for surgical management of miscarriage and abortion: a randomized controlled trial.

BACKGROUND: Women undergoing office-based surgical management of a failed or undesired pregnancy often report fear of pain and anxiety pertaining to the procedure. Doulas are trained to specifically address women's physical and emotional needs in obstetric care, and recently have extended their practice to support women through all pregnancy outcomes. OBJECTIVE: We sought to evaluate the impact of doulas on patients' physical and emotional responses to surgical management of a first-trimester failed or undesired pregnancy under local anesthesia. STUDY DESIGN: In this nonblinded, randomized trial, women received doula support or routine care during office uterine aspiration for failed or unwanted pregnancies in the first trimester. The primary outcome was pain measured on a 100-mm visual analog scale. Secondary outcomes included satisfaction, emotional state, sense of personal empowerment, and ability to cope immediately and 1 month after the procedure, as well as medical assistants' assessment of the doula's utility. A sample size of 35 per group (N = 70) was planned to detect a 20% difference in pain score. RESULTS: From April 2014 through January 2015, 129 women were screened and 70 were randomized. The 2 study groups were similar on all baseline characteristics. The primary outcome was not different between the doula and control groups (pain score 70.7 ± 24.5 mm vs 59.7 ± 32.5 mm, P = .11, respectively), even after controlling for procedure indication (P = .20). While 97% of women who received doula support reported this helped with their experience, there was no statistically significant difference in satisfaction, emotional response, sense of empowerment, or perceived ability to cope between the 2 groups of women immediately following or 1 month after the procedure. Of all study participants, 72% reported that it was important to have someone with them during the procedure, but that the support person did not have to be a doula. CONCLUSION: Doula support during office uterine aspiration for failed or undesired pregnancies is well received and desired by women undergoing this procedure despite no significant effect on physical comfort or emotional responses related to the procedure. This may suggest an unmet psychosocial need for procedure-related support among such women.

Family planning in Southern India: A survey of women's attitudes.

Women were recruited from villages in the Belgaum district of India. Members of the research team obtained consent and led 58 interviews in the local languages. Participants were asked questions covering topics related to postpartum contraceptive counseling, knowledge, and experience; postpartum sexual practice; birth spacing desire and counseling; and interest in long-acting reversible contraceptives (LARCs). Women generally desired 3 years of birth spacing. A majority did not receive counseling regarding postpartum contraception during the prenatal period, although most would have liked to have received such counseling. Those who had made a contraceptive plan during the prenatal period had an odds ratio of 25.2 (95% CI 4.9-128.6, p = 0.00001) for using postpartum contraception. Influences on contraceptive decisions primarily came from friends and family, while information from medical providers was not a major influence. Most women did not believe they could make their own decisions regarding contraception use, but those who did had an adjusted odds ratio of 56 (95% CI 3.4-9161, p = 0.0047) of utilizing postpartum contraception. Women generally liked the idea of LARCs. A large majority of the women surveyed (89.66%) liked the idea of a subdermal contraceptive implant, a method currently unavailable in this region. Ultimately, the women surveyed do have healthy attitudes and goals regarding birth spacing but few utilize effective contraception in order to meet their goals. Further efforts in counseling as well as availability of a wider variety of contraceptive methods, including the subdermal contraceptive implant, may decrease the disparity between desires and practices.

Peer counselling for the promotion of long-acting, reversible contraception among teens: a randomised, controlled trial.

AIM: To evaluate the impact peer counselling has on same-day desire for long-acting, reversible contraception (LARC) among adolescents attending a family planning clinic. METHODS: A randomised, controlled trial of 110 adolescent females attending an outpatient clinic for contraception in 2013. Adolescents received either brief peer counselling about LARC with routine contraceptive counselling, or routine counselling alone. Bivariate analyses and multivariable logistic regression assessed the primary outcome of same-day desire for LARC and secondary outcomes of change in knowledge and attitudes regarding LARC. RESULTS: Peer counselling was well received and 70% reported that it was helpful in contraceptive decision-making. Peer counselling did not affect same-day desire for LARC, however, adolescents who received the intervention were more likely to report increased knowledge and positive change in attitudes towards LARC (adjusted odds ratios: 6.6 (95% confidence interval: 2.0-22.0 and 6.4 (1.6-26.8), respectively). Factors positively associated with same-day LARC desire included greater reported peer contraceptive influence, peer use of LARC and social support. Twenty of the 36 adolescents who desired LARC at the end of their clinic visit did not receive one most commonly due to a need to schedule a specific appointment for the procedure and the need to return during a menstrual period for intrauterine device placement. CONCLUSION: While brief, point-of-care peer counselling is well received, and can increase adolescent knowledge and positive attitude about our most effective contraceptive methods, barriers to same-day LARC placement limit immediate use.

Mifepristone prior to osmotic dilators for dilation and evacuation cervical preparation: A randomized, double-blind, placebo-controlled pilot study.

OBJECTIVES: To evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. STUDY DESIGN: We performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). RESULTS: Of the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6-3.6]) compared to placebo (2.6 cm[2.2-3.0]) group, p = 0.03. Surgeon's perception of procedure being "easy" (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. CONCLUSION: Our underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. IMPLICATIONS: Mifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.

Clinical correlates of filarial infection in Haitian children: an association with interdigital lesions.

To assess clinical findings associated with Wuchereria bancrofti infection, 192 school children in a filariasis-endemic area of Haiti underwent physical and ultrasonographic examinations and testing for circulating filarial antigen (CFA). The CFA-positive children were more likely than CFA-negative children to have severe interdigital lesions (> or = 1 macerated lesion with involvement of > or = 4 toe web spaces) (P < 0.0001) and inguinal (P = 0.003) or crural (P = 0.004) lymph node pathology. In multivariate analysis, CFA positivity remained a significant predictor for severe interdigital lesions (P = 0.006) and inguinal lymph node pathology (P = 0.05). Ultrasound detected adult worms and lymphangectasia (diameter = 2.0-4.0 mm) in 11 (10.8%) CFA-positive children. Among CFA-positive children, ultrasonographic detection of adult worms was associated with inguinal (P = 0.01) and crural (P = 0.004) lymph node pathology and advanced pubertal stage (sexual maturity rating = 3-5) (P = 0.02). This is the first study to associate interdigital lesions with filarial infection in children.

Ultrasonographic examination of Haitian children with lymphatic filariasis: a longitudinal assessment in the context of antifilarial drug treatment.

To assess the clinical findings associated with detection of adult Wuchereria bancrofti worms on ultrasound, 186 schoolchildren in a filariasis-endemic area of Haiti underwent physical and ultrasonographic examinations. The filaria dance sign (FDS) of adult W. bancrofti was detected in the inguinal and crural lymphatics of 28 (15%) children. FDS detection was more common in older children (P = 0.003) and in those with a history of inguinal lymph node inflammation (P = 0.002) or crural lymphadenopathy on physical exam (P = 0.01). Twenty-five FDS-positive children were reexamined after three annual cycles of mass treatment for lymphatic filariasis (LF). The total number of adult worm nests detected by ultrasound decreased from 29 to 4 (P

Sudden intrapartum fetal death in fetuses with absent pulmonary valve syndrome: report of two cases.

Objective To describe potential intrapartum complications for fetuses affected by absent pulmonary valve syndrome. Study Design Two cases of intrapartum fetal death at full term were collected from our institution's labor and delivery unit records. Results In both cases of intrapartum fetal death, the fetuses had been diagnosed with absent pulmonary valve syndrome and had likely experienced acute cardiac events during labor. Both were delivered as stillbirths despite emergency cesarean delivery. Conclusion Patients should be counseled prior to labor about potential intrapartum complications for a fetus with absent pulmonary valve syndrome. Plans for fetal monitoring and the extent of aggressive intervention should be in place before labor in case sudden complications occur.

Dehalococcoides ethenogenes strain 195 reductively dechlorinates diverse chlorinated aromatic pollutants.

Dehalococcoides ethenogenes strain 195 dechlorinates tetrachloroethene to vinyl chloride and ethene, and its genome has been found to contain up to 17 putative dehalogenase gene homologues, suggesting diverse dehalogenation ability. We amended pure or mixed cultures containing D. ethenogenes strain 195 with 1,2,3,4-tetrachlorodibenzo-p-dioxin, 2,3,7,8-tetrachlorodibenzo-p-dioxin, 2,3-dichlorodibenzo-p-dioxin, 1,2,3,4-tetrachlorodibenzofuran, 2,3,4,5,6-pentachlorobiphenyl, 1,2,3,4-tetrachloronaphthalene, various chlorobenzenes, or a mixture of 2-, 3-, and 4-chlorophenol to determine the dehalogenation ability. D. ethenogenes strain 195 dechlorinated 1,2,3,4-tetrachlorodibenzo-p-dioxin to a mixture of 1,2,4-trichlorodibenzo-p-dioxin and 1,3-dichlorodibenzo-p-dioxin. 2,3,4,5,6- Pentachlorobiphenyl was dechlorinated to 2,3,4,6- and/or 2,3,5,6-tetrachlorobiphenyl and 2,4,6-trichlorobiphenyl. 1,2,3,4-Tetrachloronaphthalene was dechlorinated primarily to an unidentified dichloronaphthalene congener. The predominant end products from hexachlorobenzene dechlorination were 1,2,3,5-tetrachlorobenzene and 1,3,5-trichlorobenzene. We did not detect dechlorination daughter products from monochlorophenols, 2,3-dichlorodibenzo-p-dioxin or 2,3,7,8- tetrachlorodibenzo-p-dioxin. D. ethenogenes strain 195 has the ability to dechlorinate many different types of chlorinated aromatic compounds, in addition to its known chloroethene respiratory electron acceptors. Remediation of sediments contaminated with aromatic halogenated organic pollutants such as polychlorinated biphenyls and polychlorinated dibenzo-p-dioxins could require billions of dollars in the coming years. Harnessing microorganisms such as Dehalococcoides spp. that detoxify these compounds via removal of halogens may lead to cost-effective biotechnological approaches for remediation.

Histopathologic improvement with lymphedema management, Léogâne, Haiti.

In countries where bancroftian filariasis is endemic, lymphedema of the leg is a public health problem, particularly for women, who are disproportionately affected. We investigated the effect of basic lymphedema management (hygiene, skin care, and lower limb movement and elevation) on the histologic features of lymphedema. A total of 118 skin-punch biopsy specimens were collected from the legs of 91 patients enrolled in a lymphedema treatment clinic in Léogâne, Haiti. Follow-up biopsy specimens were collected from 27 patients succeeds, equals 12 months later. Keratinocyte hyperproliferation, condensed dermal collagen, and mononuclear perivascular infiltrate increased with lymphedema stage, which suggested progressive chronic inflammation and fibrosis. Follow-up biopsies showed reductions in perivascular mononuclear infiltrate in the superficial dermis (41% decrease in prevalence), perivascular fibrosis in the deep dermis (58% decrease), and periadnexal mononuclear infiltrate (53% decrease). These data suggest that the clinical improvement commonly observed with basic lymphedema management has a histologic basis.