Risk of unsafe abortion associated with long-term contraception behaviour: a case control study from Sri Lanka.

BACKGROUND: When faced with an unintended pregnancy, some women choose to undergo an unsafe abortion, while others do not. This choice may depend on long-term contraception that shapes the fertility goals of women, along with many other risk factors. We assessed the risk for unsafe abortion associated with contraceptive practices based on women's long-term behaviour, and its likely modification by the use of different types of contraceptives among women in Sri Lanka. METHODS: An unmatched case-control study was conducted in nine hospitals among 171 women admitted for care following an unsafe abortion (Cases) and 600 women admitted to same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires assessed their socio-economic, reproductive and fertility (decisions on family size, family completion) characteristics, contraceptive method last used (traditional, modern), reasons for discontinuation/never-use, and contraceptive practices assessed at different time points. Using several regression models, the risk of abortion was assessed for 'non-use' of contraception against 'ineffective use' at conception; for non-use further categorised as 'never-use', 'early-discontinuation' (discontinued before last birth interval) and 'late-discontinuation' (discontinued during last birth interval); and for any interaction between the contraceptive practice and contraceptive method last used among the ever-users of contraception. RESULTS: At conception, 'non-use' of contraception imparted a two-fold risk for abortion against ineffective use (adjusted-OR = 2.0; 95% CI: 1.2-3.2). The abortion risk on 'non-use' varied further according to 'early' (adjusted-OR = 1.7; 95% CI: 1.1-3.1) and 'late' (adjusted-OR = 2.3; 95% CI: 1.5-3.6) discontinuation of contraception, but not with 'never-use' (crude-OR = 1.1; 95% CI: 0.6-2.3). Among the ever-users, the risk of abortion varied within each contraceptive practice by their last used contraceptive method and reasons for discontinuation. A significant interaction between modern contraceptives and early discontinuation (adjusted-OR = 1.4; 95% CI = 1.1-3.1) demonstrated a seven-fold abortion risk for early discontinuation of modern methods against its ineffective use. In particular, hormonal methods seemed to be responsible for this risk (51.1% cases versus 42.5% controls). CONCLUSIONS: Long-term contraceptive practices showed varying risk for abortion, and was further modified by early discontinuation of modern contraceptives. This knowledge should be applied during postnatal visits by public-health staff.

Relationship of family formation characteristics with unsafe abortion: is it confounded by women's socio-economic status? - A case-control study from Sri Lanka.

BACKGROUND: Literature shows that choice for unsafe abortion is often driven by poverty. However, factors related to the family formation behaviour of women are also implied as determinants of this decision. This study assessed which family formation characteristics of women are associated with the risk of unsafe abortion, without being confounded by their low socio-economic status among Sri Lankan women admitted to hospital following post-abortion complications. METHODS: An unmatched case-control study was conducted in nine hospitals in eight districts in Sri Lanka among 171 women with post-abortion complications following unsafe abortion (Cases) and 600 postpartum mothers admitted to same hospitals during the same period for delivery of term unintended pregnancies (Controls). Interviewer-administered-questionnaires obtained demographic, socio-economic and family formation related characteristics. Risk factors of abortion were assessed by odds-ratio (OR), adjusted for their socio-economic status in logistic regression analysis. RESULTS: Low socio-economic status, characterised by low-education (adjusted OR = 1.5; 95 % CI = 1.1-2.4) and less/unskilled occupations (2.3; 1.4-3.6) was a significant risk factor for unsafe abortion. Independent of this risk, being unmarried (9.3; 4.0-21.6), failure in informed decisions about desired family size (2.2; 1.4-3.5), not having a girl-child (2.2; 1.4-3.4) and longer average birth intervals (0.7 years; 0.6-0.8) signified the vulnerability of women for unsafe abortion. Cases were as fast as the controls in their family completion (4.3 versus 4.5 years; p = 0.4), but were at increased risk for abortion, if their average birth intervals (including the last one) were longer. Previous contraceptive use, age at reproductive events or partners' characteristics did not impart any risk for abortion. CONCLUSIONS: Low socio-economic status is not the most influencing risk factor for unsafe abortions leading to complications, but many other factors in relation to their family formation characteristics that are independent of their low socio-economic status.

Usual hospital care versus post-abortion care for women with unsafe abortion: a case control study from Sri Lanka.

BACKGROUND: Good quality post-abortion-care (PAC) is essential to prevent death and long-term complications following unsafe abortion, especially in countries with restrictive abortion laws. We assessed the PAC given to women following an unsafe abortion, compared to the routine hospital care following spontaneous abortion or unintended pregnancy carried to term in Sri Lanka. METHODS: A case-control study was conducted in Sri Lanka among 171 cases following unsafe abortion, 638 controls following spontaneous abortion (SA-controls) and 600 women following delivery of an unintended pregnancy (TUP-controls) admitted to same hospitals during the same period. Care provided was assessed using interviewer-administered-questionnaires and in-depth-interviews at hospital discharge and in a sub-sample, at 6-8 weeks post-discharge. Differences in care were assessed using chi-square tests. RESULTS: Mean age of cases was 30.6 years (SD = 6.6); 21.1% were primis. 60.8% cases developed sepsis and 12.3% organ failure. Cases received timely, complete and safe emergency treatment with no difference to SA-controls (p > 0.05): removal of retained products of conception medically (14.6% cases versus 19.4% SA-controls) or surgically (73.7% versus 75.1%), within 24 hours of admission (63.5% versus 52.8%), under anaesthesia (84.1% versus 92.3%) and intravenous antibiotics (91.2% versus 31.0%). Despite this equitable treatment, cases were dissatisfied with their overall care during hospital stay, predominantly due to verbal harassment of health-care-providers on their abortion status (57.9% versus 19.3% SA-controls, p < 0.05). Ward doctors provided the best care to cases in all aspects, except compared to SA-controls in explaining women's health status (60.2% versus 77.7%), and compared to TUP-controls in providing information on contraceptive methods (14% versus 24.3%), service availability (13.5% versus 24.7%) and assistance in decision-making on contraception (13.5% versus 21.3%). Ward-midwives contributed none to family-planning care of cases. At 6-8 weeks, 48.9% of cases were on contraceptive methods, predominantly short-term, compared to 85.3% of TUP-controls, predominantly long-term methods (p < 0.01). CONCLUSIONS: Despite equitable emergency treatment, care following unsafe abortion was deficient in post-abortion counselling, education and family planning services. Engagement of public-health staff for follow-up care was inadequate. Perceived dissatisfaction of overall care was owing to discrimination related to their abortion status.

Decision making on unsafe abortions in Sri Lanka: a case-control study.

BACKGROUND: Following an unintended pregnancy, not every woman would invariably choose to undergo an unsafe abortion. It suggests that in the decision making process, women face both 'push' factors that favour abortion and 'pull' factors that work against it. This study assessed the circumstances that surrounded a woman's decision to undergo an unsafe abortion, compared to a decision to continue, when faced with an unintended pregnancy in Sri Lanka. METHODS: An unmatched case-control study was conducted among 171 women admitted to nine hospitals in eight districts following an unsafe abortion (Cases) and 600 women admitted to the same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires and in-depth interviews assessed women's characteristics, decision making process and underlying reasons for their decision. The risk of abortion related to their decision making was assessed using odds ratio (OR) and 95% confidence interval (CI). RESULTS: Compared to controls, the cases were significantly less-educated, employed, unmarried and primi-gravid (p < 0.05). All knew the 'illegal' status of abortion, mainly through media (65.5% cases versus 80% controls). When making a decision, the risk of undergoing an unsafe abortion was significant among those who sought assistance (44% versus 32%; OR = 1.7 (95% CI = 1.2-2.4)), with more reliance placed on non-medical sources such as spouse/partner, friend, neighbour and family/relation. Speaking to women with past experience of induced abortions (31% versus 21.5%; OR = 1.6 (1.1-2.4) and failure in making the final decision with partners also imparted a significant risk for abortion (64% versus 34%; OR = 3.4; 2.4-4.8). A decision favouring unsafe abortion was predominantly based on their economic instability (29.5%) and poor support by partners (14%), whereas a decision against it was based on ethical considerations (44% religious beliefs: 12% social stigma) over its legal implications (4%). Most abortions were performed by unqualified persons (36.1% self proclaimed abortionists; 26.2% not revealed their qualifications) for a wide range of payment in non-sterile environments (45.9% unknown place) using septic procedures (38.5% trans-vaginal insertions; 24.6% unaware of the procedure). CONCLUSIONS: Women's risk of unsafe abortion was associated with unreliable sources of information during decision making that led to poor knowledge and positive attitudes on its safety; poor access to affordable abortion services; and their economic instability.

Psychometric properties of the Sinhala version of the PedsQL™ 4.0 Generic Core Scales in early adolescents in Sri Lanka.

BACKGROUND: The concept Health related Quality of life (HRQOL) is increasingly recognized as an important health outcome measure in clinical and research fields. The present study attempted to evaluate the psychometric properties of the Sinhala version of the Pediatric Quality of Life Inventory™ 4.0 (PedsQL™ 4.0) Generic Core Scales among adolescents in Sri Lanka. METHODS: The original US PedsQL™ was translated into Sinhala and conceptually validated according to international guidelines. A cross-sectional study was conducted among 142 healthy school going adolescents (12-14 years), their parents (n = 120) and a group of adolescents with asthma who attended asthma clinics (n = 115). Reliability was assessed using Cronbach's alpha and validity by examining scale structure, exploring inter-scale correlations and comparing across known groups (healthy vs. chronically ill). RESULTS: The PedsQL™ Sinhala version was found to be acceptable with minimal missing responses. All scales demonstrated satisfactory reliability. Cronbach's alpha for the total scale scores was 0.85 for adolescent self-report while for the parent proxy-report for the healthy group it was 0.86. No floor effects were observed. Ceiling effects were noticed in self-report and parent proxy-report for the healthy group. Overall results of the multi trait scaling analysis confirmed the scale structure with 74% item-convergent validity, 88% item-discriminant validity and an overall scaling success of 72%. Moderate to high correlations were shown among the domains of teen self-report (Spearman rho = .37-.54) and between teen self-report and parent proxy-reports (Spearman rho = .41-.57). The PedsQL™ tool was able to discriminate between the quality of life in healthy adolescents and adolescents with asthma. CONCLUSION: The findings support the reliability and validity of the Sinhala version of the PedsQL™ 4.0 Generic Core Scales as a generic instrument to measure HRQOL among early adolescents in Sri Lanka in a population setting.

Health-related quality-of-life in patients with head-and-neck cancer in Sri Lanka: psychometric properties of the 'Sinhala' version of the EORTC QLQ-H&N35.

OBJECTIVE: To translate and validate the 'Sinhala' language version of the European Organization for Research and Treatment of Cancer head-and-neck cancer-specific health-related quality-of-life questionnaire module, the QLQ-H&N35, for use in Sri Lanka. METHODS: Psychometric testing assessed the hypothesized scale structure, scale reliability, construct validity and acceptability of the translated version of the QLQ-H&N35 in a consecutive series of 196 newly diagnosed head-and-neck cancer patients, recruited from tertiary-care oncology treatment centres in Sri Lanka. RESULTS: Compliance was high (97.5%), although nearly 40% of patients required assistance with completion of the questionnaire. Twenty-four sexually inactive patients declined to answer one or both items of the sexuality scale. Multi-trait scaling confirmed the overall scale structure, with good item-convergent (100%) and -discriminant (93.8%) validity, and scaling success (86.8%) rates. Cronbach's alpha coefficients exceeded 0.70 for all scales, except problems with sexuality (0.60) and problems with senses (0.61), which also evidenced a lower scaling success rate (50%). Confirmation of construct validity included satisfactory results for inter-scale correlations and known-groups comparisons for most scales; most correlations were statistically significant (p<0.01), with conceptually related scales showing relatively higher correlation. Most scale scores were able to discriminate clearly between pre- and current treatment patients. CONCLUSIONS: Results of the study provide strong support for the psychometric robustness of the 'Sinhala' version of the QLQ-H&N35. It may be advisable to interpret the two items assessing sensory problems separately, and to elicit information on sexuality from only those who are sexually active.

The EORTC QLQ-CX24 cervical cancer-specific quality of life questionnaire: psychometric properties in a South Asian sample of cervical cancer patients.

OBJECTIVE: The cervical cancer-specific Quality of Life module of the European Organization for Research and Treatment of Cancer, EORTC QLQ-CX24, was recently validated in an international field study that did not include cervical cancer patients from South Asia. The aim of our study was to assess the psychometric properties of the instrument in a sample of cervical cancer patients from Sri Lanka to assess its suitability for use in the South Asian region. METHODS: One hundred and twelve newly diagnosed patients with cervical cancer completed the translated version of the QLQ-CX24 in a cross-sectional validation study. Psychometric evaluation assessed the instrument for scale structure, scale reliability, validity and acceptability. RESULTS: The QLQ-CX24 was found to be patient-friendly with high compliance and low missing data. Only a few patients needed assistance for completion. Overall results for multitrait scaling analysis confirmed the scale structure although some items of the symptom experience scale exhibited problems regarding item-scale correlations with its own scale. Cronbach's alpha coefficients for internal consistency ranging from 0.63 to 0.79 confirmed scale reliability. Construct validity was confirmed in two ways: the inter-scale correlations were statistically significant (p<0.01) and their magnitude moderate (r = 0.52-0.58) while the scales and single-item measures were able to discriminate between subgroups of patients differing with regard to treatment status. CONCLUSION: The translated version of the QLQ-CX24 is a reliable and valid instrument to measure cervical cancer-specific Quality of Life in Sri Lanka. The overall results are in line with the findings of the international field study.

Genetic, familial and environmental correlates of asthma among early adolescents in Sri Lanka: a case control study.

BACKGROUND: Despite advances in management, the mortality and morbidity due to asthma are increasing globally. Identification of specific correlates in the local context is useful in disease management. The objective of this study was to estimate the prevalence and to describe selected correlates of asthma among12-14 year old school children in a district in Sri Lanka. METHOD: A school based cross-sectional study was conducted using a self administered questionnaire. Multi-staged stratified cluster sampling was used to select 42 classes in grades 7, 8 and 9. "Current asthma" (CA)(case) was defined as 'having Physician Diagnosed Asthma (PDA) and having had wheezing during the previous 12 months'. For each case, two healthy controls were selected from the same class to assess correlates. Information on correlates was collected by trained field midwives during home visits. Backward stepwise logistic regression model was used for analysis of correlates. Skin Prick Testing was carried out among asthmatics together with their healthy siblings using standard extracts of House Dust Mite (HDM), cockroach and Blomia. Ethical clearance was obtained from Ethical Review Committee, Faculty of Medicine, Colombo. RESULTS: Out of 1483 subjects participated, 753 were females (50.8%). The prevalence rates for current wheezing (CW), ever wheezing (EW), current asthma (CA), and physician diagnosed asthma (PDA) were 16.7%, 19.4%, 10.7% and 14.5% respectively. A total of 158 CA cases were identified. Information on correlates of asthma was collected for 145 CA cases (97.9%) and for 285 controls (96.6%). The unconfounded predictors of having CA among adolescents in the present sample were; only child in the family (OR = 4.2, 95% CI: 1.7-9.9); first born of the family (OR = 2.6 95% CI: 1.3-5.2); presence of allergic rhinitis (OR = 2.7, 95% CI: 1.6-4.6); family history of asthma (OR = 1.8, 95% CI: 1.1-3.2); family history of allergic rhinitis (OR = 1.9, 95% CI: 1.1-3.2); family history of eczema (OR = 1.8, 95% CI: 1.0-3.2). Higher risk of sensitization to cockroach, HDM and Blomia was seen among asthmatics compared to healthy siblings. CONCLUSION: A significant proportion of students reported to have asthma. Atopy and other genetic and environmental correlates should be considered as important correlates in asthma management among early adolescents in Sri Lanka.

A "usual occurrence:" stress incontinence among reproductive aged women in Sri Lanka.

Stress urinary incontinence (SUI) is a common condition among women of all ages, often with devastating consequences, such as depression, anxiety and reduced quality of life. Researchers have largely focused on its prevalence and clinical management, particularly in highly industrialized country settings. In this article, drawing on epidemiological, clinical and qualitative research undertaken in Sri Lanka, we discuss how stress incontinence affects women's lives and how they personally manage the problem. Quantitative data derive from a community-based descriptive cross-sectional study, conducted in 2006-2007 with 1718 ever-married women, aged 15-49, of whom 9.8% reported problems of stress incontinence. Six focus group discussions, eight key informant interviews and five case studies with women with SUI were also undertaken to gain insight and depth. Although incontinence affected outdoor activities, sexual life, and sense of wellbeing, women did not consider it a health problem, rarely discussed it with others, and rarely sought treatment. Barriers to help seeking included fear of vaginal examination, shame and embarrassment, and belief that SUI was a natural consequence of aging and childbirth. Women's reluctance to seek advice on their own initiative about managing incontinence indicates the importance for health providers to pay greater attention to the condition and introduce appropriate preventive measures for women. This might include creating greater public awareness of SUI as preventable and treatable, ensuring a clinical environment conducive to discussing problems related to bodily functions.

Measuring breast cancer-specific health-related quality of life in South Asia: psychometric properties of the Sinhala version of the EORTC QLQ-BR23.

OBJECTIVE: To evaluate the psychometric properties of the Sinhala version of the breast cancer-specific health-related quality of life (HRQL) module of the European Organization for Research and Treatment of Cancer (QLQ-BR23). METHODS: Psychometric testing assessed the hypothesized scale structure, internal consistency, construct validity and acceptability of the Sinhala version of the QLQ-BR23 in a consecutive series of 356 newly diagnosed breast cancer patients recruited from tertiary care oncology treatment centres in Sri Lanka. RESULTS: Compliance and self-completion rates were high (98% and 88%, respectively), and missing data low (0.06%). Multitrait scaling confirmed the scale structure of the QLQ-BR23 with excellent item convergence (95%), item discrimination (99%), and scaling success (99%) rates. The Cronbach's alpha coefficients of the scales for internal consistency reliability ranged from 0.68 to 0.93. Construct validity was confirmed with satisfactory results for interscale correlations and known-groups comparisons. QLQ-BR23 item-scale correlations met or exceeded the convergent validity criterion of 0.40 for all but one item. QLQ-BR23 interscale correlations met this criterion for three comparisons and for five comparisons with conceptually related QLQ-C30 scales. Correlations between QLQ-BR23 scales and QLQ-C30 functional scales were lower as expected. As expected, most dimensions of the QLQ-BR23 were able to discriminate clearly between pretreatment and current treatment patients. CONCLUSION: Overall psychometric results for the Sinhala version of the QLQ-BR23 confirmed it as a reliable and valid questionnaire for assessing breast cancer-specific HRQL in Sri Lanka.

Quality of life in cancer patients in South Asia: psychometric properties of the Sinhala version of the EORTC QLQ-C30 in cancer patients with heterogeneous diagnoses.

BACKGROUND: The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) was evaluated for its psychometric properties in a sample of cancer patients from the culturally distinct South Asian subcontinent, which accounts for a significant proportion of the global cancer burden. METHODS: Psychometric testing assessed the hypothesised scale structure, internal consistency, content and construct validity, and acceptability of the Sinhala version of the QLQ-C30 independently in two heterogeneous groups of cancer patients at pretreatment (N = 489) and during treatment (N = 343). RESULTS: Qualitative feedback from an expert panel assessing content validity recommended measuring family support during illness as an additional, culturally-relevant dimension of health-related quality of life (HRQL). Compliance was high (100%), with little missing data (0.11%). Multitrait scaling results supported the scale structure of the QLQ-C30, with the exception of the cognitive functioning scale, which was also the only scale that did not meet the 0.70 internal consistency criteria in either sample. Interscale correlations were of a moderate size, with conceptually related scales showing higher correlations. All scales were able to discriminate clearly between pre- and current treatment patients (P < 0.01), although results were less consistent when comparing groups formed on the basis of age and disease stage. CONCLUSIONS: Overall psychometric results confirmed the QLQ-C30 as a reliable and valid questionnaire for assessing HRQL of cancer patients in Sri Lanka.

COVID-19 health system response monitor: Sri Lanka

The COVID-19 Health System Response Monitor presents findings from a systematic approach to collect and synthesize up-to-date information on Singapore’s policy response to the COVID-19 outbreak. This publication is part of the APO’s COVID-19 HSRM series which presents detailed information on country-specific responses to COVID-19, to facilitate easy comparisons of health systems and public health, and policy responses to COVID-19. It also aims to strengthen evidence on the global response to the pandemic and allow for easy comparison of activities at national and sub-national levels. The series is updated to reflect changes in the health systems and policies to the COVID-19 response.