Ectopic pregnancy mortality, United States, 1979 to 1980: clinical aspects.

Ectopic pregnancy has recently become a major cause of maternal mortality in the United States. Despite its increasing public health impact, relatively little is known about the clinical epidemiology of this condition. Therefore, the authors investigated all reported deaths from ectopic pregnancy in the United States occurring in 1979 and 1980, to determine characteristics of, and risk factors for, fatal ectopic pregnancy. Most women (85%) died from hemorrhage. Abdominal and interstitial implantations were more likely to become symptomatic later in gestation and to be fatal than were tubal implantations. Of those deaths for which circumstances were known, more prompt diagnosis and treatment of ectopic pregnancy by health professionals might have prevented one-half of the deaths. One-third of the deaths might have been prevented if the women had notified or visited a physician more promptly after the onset of symptoms. Timelier action by women and health professionals could reduce ectopic pregnancy mortality.

AIDS Community Demonstration Projects for HIV prevention among hard-to-reach groups.

The AIDS Community Demonstration Projects are multicenter prevention projects directing community-based interventions to members of hard-to-reach groups at risk of infection from human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS). The projects are supported by the Centers for Disease Control (CDC). Interventions are derived from theories of behavior change and have as their goal reducing HIV and other sexually transmitted diseases in the communities. The current objectives, intentionally narrow to improve the project's specificity and clarity, are to increase the use of condoms in sexual activity and the use of bleach to clean injecting drug equipment. Additional objectives may be added. The impact of the interventions is seen in increases in the use of HIV counseling and testing services, decreases in all or specific sexual and drug-use risk behaviors, and requests for related social and public health services. A quasi-experimental research design is being used to evaluate the projects. Multiple evaluation measures are used, including a street-based interview with randomly identified respondents in both intervention and control communities. Success in facilitating HIV and AIDS risk reduction is being measured using a model of behavior change describing stages of change. Upon successful completion of these projects in 1994, CDC may be able to offer models of effective, feasible, and easy-to-monitor State and local health departments and community-based organizations.

Sexual behaviour, perceptions of infertility and family planning in sub-Saharan Africa.

PIP: Sexually transmitted diseases (STD) are a particular problem in the developing world. Sexual behavior and rapid societal changes appear to be contributing to the high prevalence. Infertility, a consequence of STD, is seen as one of the most devastating things that could happen to an African woman. Behavioral risk factors for STD include age at 1st intercourse, number of sexual partners and use of contraception. The 1st two indicate length of exposure and amount of exposure respectively. Along with the prevalence of STD in the community, these factors allow an estimate of the population at risk for STD. Demographic risk factors from developed countries may not be applicable to developing countries. Data on sexual behavior in Africa is poor. Great intercultural variation exists. Age at 1st intercourse is earlier in Africa than America, with over 1/3 of African women reporting sexual activity by age 14, and 90% by age 17. Premarital sexual activity is high. Prostitution is widespread in African cities, and has been related to lack of expectations for marital fidelity, premarital celibacy and the infrequency of romantic love. Prostitutes play an important role in STD transmission. Current population growth in Africa has skewed the population towards the young, there has been rural to urban migration, and there are skewed sex ratios with many more men in cities: all of these factors predispose to STD. The high prevalence of untreated STD, resulting in increased infertility acts paradoxically to increase rather than decrease the fertility in Africa. Infertility is devastating for an African woman, resulting in divorce and diminished social status that often leads to prostitution. The fear of infertilty results in refusal of contraception and early childbearing to demonstrate fertiltiy.^ieng

International perspectives on individual and community approaches to the prevention of sexually transmitted disease and human immunodeficiency virus infection.

Risks for sexually transmitted disease (STD) and human immunodeficiency virus (HIV) infection have been addressed in two categories: the individual and the population. Emphasis in STD and HIV prevention has largely been placed on the first, with interventions that address individuals and attempt to bring about changes in individuals being the norm. The relative ease of evaluating these interventions and the ability to know that they have been delivered as intended make these interventions attractive. Community interventions are more difficult to manage and to evaluate but are nonetheless commonly used. Structural interventions that address the environment in which risk behavior takes place are also possible but used much less frequently. In a comprehensive intervention program for STD and HIV prevention, it is necessary to consider opportunities for all three types of intervention approaches.

Adolescence and sexual behavior. Trends and implications for STD.

Teenage sexual activity became more common in the 1970s, and that trend may continue in this decade. Teenagers have thus established themselves as an important component of the population at risk of sexually transmitted disease (STD). Adolescents exhibit many of the same features of sexual behavior seen in the adult population. However, adolescents' abilities to recognize, evaluate symptoms of, and seek treatment for STD are generally limited. Many teenagers are hesitant to admit that they have begun sexual activity or that something like STD could happen to them. The combination of these factors with generally liberalizing trends in sexual behavior in the last decade has elevated the risk of STD for teenagers and made the job of adolescent health care providers more difficult.

Contraceptive practices of women attending the Sexually Transmitted Disease Clinic in Nashville, Tennessee.

The decision to be sexually active involves two health risks for women: unwanted pregnancy and sexually transmitted diseases. Use of contraception affects both these risks. Data from the Metropolitan Health Department in Nashville, Tennessee, were examined to determine the effects of particular contraceptive methods on gonococcal infection in women. The results suggest that not only barrier methods but also other types of contraception were associated with protection against gonorrhea in females. The use of contraception was unusually high (87%) among the study population of 1,303 women. Five hundred eighteen (40%) of these clinic attendees were infected with Neisseria gonorrhoea. Infected women tended to be younger than those not infected and were significantly more likely to be black than white and somewhat more likely to be single. Contraceptors tended to be younger and were more likely to be black than were noncontraceptors.

PIP: The effects of particular contraceptive methods on gonococcal infection were examined in 1303 women attending a public venereal disease clinic during 1979. 1132 (87%) of clinic attenders were using some method of fertility control. The major methods in this series were oral contraceptives, 47%; surgical methods, 18%, and IUDs, 12%. Barrier methods accounted for 5% of contraceptive usage. Of all the women who came to the clinic, 518 (40%) were actually infected with N gonorrhoeae. Those infected with N gonorrhoeae were likely to be younger than those not infected and were more often black and single. Significantly more noncontraceptors than contraceptors were black and young (under 20 years of age). Women not using contraceptives were over 3 times more likely to be infected than contraceptive users (94% infection rate versus 30%). All methods of contraception provided some degree of protection against gonococcal infection. Barrier methods appeared to have the strongest protective effect; only 9.4% of barrier method users were infected (relative risk 0.11). In some cases, the relationship observed in this study between use of specific contraceptive methods and lower rates of gonorrhea may be biological. The explanation in other cases may be behavioral: women who use birth control may be less risk taking in their sexual behavior. It is concluded that motivating women to use contraception, especially barrier methods, could help reduce the incidence of sexually transmitted diseases. Extrapolation of the findings of this study suggests that nearly 200,000 of the 250,000 cases of gonorrhea reported in the US in 1983 could have been averted by use of barrier methods of contraception on the part of noncontraceptors and those using nonbarrier methods.

An evaluation of sexual behaviour change using statistical and cognitive models. The AIDS Community Demonstration Projects.

We evaluate sexual behaviour change among homosexual men enrolled in the cohorts in four AIDS Community Demonstration Projects. Behaviour change is classified following the stages of behaviour change model and described using a Markov model. Predictors of behaviour change are identified and evaluated using logit models for correlated data. Sexual behaviour change within the cohort could be modelled as a first-order Markov process. In addition, predictors suggested by models of health behaviour were correlated with particular patterns of sexual behaviour change. Our evaluation revealed a variety of patterns of sexual behaviour change in the cohorts and suggests multi-faceted interventions for promotion of behaviour change.

Gonococcal infections in women attending the Venereal Disease Clinic of the Nashville Davidson County Metropolitan Health Department, 1984.

During the first six months of 1984, slightly more than a third (34.1%) of the 1,549 women who attended the Venereal Disease Clinic of the Nashville Davidson County Health Department in this study were found to be infected with Neisseria gonorrhoeae. Infection prevalence was 36.7% for black women and 27.1% for white. The frequency of sexual intercourse and the number of sexual partners during the previous 30 days were similar for black and white patients. Fewer women were using contraceptives (67.8%) than in 1979 (87%). Exceptionally high rates of infection were found in women whose sexual partners had gonorrhea. Even with similar levels of sexual activity, black women faced greater risk of infection than white women, possibly because they were much more likely to be exposed to an infected man.

Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits?

It has been widely believed that, by combining the services for preventing and treating sexually transmitted infections (STI) with those for family planning (FP), STI coverage would increase and the combined service would be of higher quality and more responsive to the needs of women. So far, there is little concrete evidence that integration has had such an impact. Besides the absence of documentation, a clear definition of integration is lacking. We therefore carried out a comprehensive review of concrete experiences with integrated services, and present a summary of our findings in this article. The results indicate that the tasks of STI prevention, such as education for risk reduction and counselling, have been integrated into family planning services much more frequently than the tasks of STI diagnosis and treatment. Some STI/FP integration efforts appear to have been beneficial, for instance when the integration of STI/HIV prevention had a positive impact on client satisfaction, and on the acceptance of family planning. Less clear is whether STI prevention, when concentrated among traditional FP clients, is having a positive impact on STI risk behaviours or condom use. A few projects have reported increases in STI caseloads following integration. In some projects, FP providers were trained in STI case management, but few clients were subsequently treated.

The epidemiology of abortion services.

PIP: The incidence of abortion and general characteristics of women obtaining legal abortions in the US, and the trends and effects of abortion during the 1970s are described. Statistics on the abortion ratio and abortion rate for the US by year from 1969 to 1978 are presented. Sociodemographic characteristics of women obtaining abortions (age, marital status, parity, gestational age and previous abortions) are described. The availability of abortion services and facilities and the types of procedures used and their safety are discussed. Factors which have contributed to the increasing number of legal abortions are discussed. The benefits of epidemiological data on abortion are noted.^ieng

Sex partner recruitment as risk factor for STD: clustering of risky modes.

Nine hundred and fourteen heterosexual persons who requested care at STD clinics in South Carolina responded to self-administered questions on STD history, socio-demographic characteristics, number of sexual partners, and sexual partner choice. These data and the current STD diagnosis were analysed using multivariate techniques. Sexual behaviors of men and women were different. Men reported greater number of partners and less discriminating sex partner recruitment patterns. Age, rural/urban residence, race, and number of sex partners were independent predictors of gonorrhea infection among men. Among women, age, rural/urban residence, and not knowing the most recent sex partner very well emerged as independent predictors of infection.

Fatal hemorrhage from legal abortion in the United States.

Deaths from hemorrhage associated with legal induced abortion should not occur. Yet hemorrhage was the third most frequent cause of death from legal abortion in the United States between 1972 and 1979. This study was undertaken to document the scope of the problem, to identify risk factors for fatal hemorrhage and to recommend ways of preventing these deaths. Deaths were identified through the CDC's nationwide surveillance of deaths from abortions; information on numbers and characteristics of women having legal abortions was obtained from CDC and the Alan Guttmacher Institute. Twenty-four women died from hemorrhage after legal abortion in the United States from 1972 to 1979, for a death-to-case rate of 0.3 deaths per 100,000 abortions (95 per cent confidence interval 0.2 to 0.5). Women who died from hemorrhage were significantly older than those who died from other causes (27.6 versus 24.4 years; p less than 0.05). Documented uterine perforation or rupture was far more frequent among women who died from hemorrhage than those who died from other causes (71 versus 8 per cent; p less than 0.001). Women who sustained uterine perforation or rupture were over 1,000 times more likely to die from hemorrhage than those who did not. Deaths from hemorrhage can be eliminated by preventing uterine trauma during abortion and by rapidly diagnosing and treating hemorrhage if it occurs.

PIP: All deaths from hemorrhage (excluding disseminated intravascular coagulation) after legal abortion in the US were analyzed and compared with legal abortion deaths from all other causes during the January 1972 to December 31, 1979 period. The cause of death in each instance was determined after review of information from the woman, her family or friends, the medical staff; clinic or hospital records; autopsy reports; and death certificates. 24 women died from hemorrhage after legal abortion in the US from 1972-79. During this interval, 7,298,000 legal abortions were reported to the Centers for Disease Control (CDC). The death to case rate for hemorrhage from legal abortion during this period was 0.3 deaths/100,000 abortions. During this same interval, 132 women died of other causes related to legal abortion. No consistent temporal trend in deaths from hemorrhage after legal abortion was evident. The death to case rate for hemorrhage by year ranged from 0.1-0.5 deaths/100,000 abortions, reflecting the small numbers of such deaths each year. The proportion of all legal abortion deaths that was attributable to hemorrhage varied widely year by year, ranging from 4-36%. Women who died from hemorrhage after legal abortion were significantly older than women who died from other causes. Uterine perforation or rupture was far more frequent among women who died from hemorrhage than from other causes (71 versus 8%). Those who died from hemorrhage were 9.4 times more likely to have sustained trauma to the uterus than those who died from other causes. Few other important differences emerged between the 2 groups. Calculation of characteristic specific death to case rates revealed several factors associated with an increased risk of death from hemorrhage. Age was a powerful risk factor for fatal hemorrhage, the risk increasing with advancing age. Hemorrhage requiring transfusion was significantly more frequent among older women. Women of minority races had a higher risk of death from hemorrhage, although this was true for other causes of death as well. Gestational age also influenced the risk of death from hemorrhage. The risk increased progressively through the 16-20 week interval, after which it declined. Overall, the risk of death from hemorrhage was higher in hospitals. Preexisting medical condtions and incomplete abortion increased the risk of death from abortion. Women who sustained uterine perforation or rupture had a risk of death from hemorrhage over 1000 times that of women without this trauma. Uterine trauma caused the bleeding in 17 of the 24 fatal instances of hemorrhage. Lack of adequate postoperative monitoring or treatment of hemorrhagic shock was common to all 24 deaths.

Legal abortion in Italy: 1980-1981.

In 1980 and 1981, there were 446,430 legal abortions performed in Italy. There were about 345 legal abortions per 1,000 live births in 1980 and 363 in 1981. About 1.6 percent of women aged 15-49 obtained abortions in both years. An analysis of the characteristics of Italian women who obtained abortions indicates that most were married (about 70 percent), aged 18-36 (74 percent), had had less than a high school education (74 percent) and had had at least one previous live birth (70-75 percent). In 1981, 88 percent of abortions were obtained in public hospitals; 58 percent were carried out at eight or fewer weeks of gestation; and 78 percent were performed under general anesthesia. Only 20 percent were performed without an overnight stay in the hospital; and over 40 percent of women were hospitalized for two days or longer. Infection after the abortion was reported in only 0.03 percent of cases in 1981, and hemorrhage was reported in only 0.27 percent. In 1981, between 43 percent and 84 percent of gynecologists (depending on the region of the country) declined to perform abortions on grounds of conscience.

PIP: In 1980 and 1981, there were 446,430 legal abortions performed in Italy. There were about 345 legal abortions/1000 live births in 1980 and 363 in 1981. About 1.6% of women aged 15-49 obtained abortions in both years. An analysis of the characteristics of Italian women who obtained abortion indicates that most were married (about 70%), aged 18-36 (74%) and had had at least 1 previous live birth (70-75%). In 1981, 88% of abortions were obtained in public hospitals; 58% were carried out at 8 or fewer weeks of gestation; and 78% were performed under general anesthesia. Only 20% were performed without an overnight stay in the hospital; and over 40% of women were hospitalized for 2 day or longer. Infection after the abortion was reported in only 0.3% of cases in 1981, and hemorrage was reported in only 0.27%. In 1981, between 43% and 84% of gynecologists (depending on the region of the country) declined to perform abortions on grounds on conscience. While almost 1/3 of all abortions are obtained by teenagers in the US, in Italy, only 3-4% are. This is closely associated with the fact that about 3/4 of legal abortions in Italy are obtained by married women, whereas in the US, the comparable proportion was only 22% in 1981. Because of legal requirement of a week's waiting period and written parental consent for minors in Italy, teenagers may be compelled to resort to illegal abortion or delivery of an unwanted child. Minors who do obtain abortions do so at a more advanced gestational stage than older women and this is even more pronounced in Italy than in the US. An outpatient procedure lasting only a few hours, the norm in the US, is still very much the exception in Italy. The goal of performing safer abortions at earlier stages of gestation has taken almost a decade to achieve in the US. It is logical to assume that such progress will be just as gradual in Italy.

Evidence for the effects of HIV antibody counseling and testing on risk behaviors.

OBJECTIVE: To review published abstracts, journal articles, and presentations for evidence of the effects of human immunodeficiency virus (HIV) antibody counseling and testing on risk behaviors. Studies reviewed focused on homosexual men, intravenous drug users in treatment programs, pregnant women, and other heterosexuals. DATA SOURCES: Peer-reviewed journals (January 1986 through July 1990) and published abstracts and oral presentations from the second (1986) through the sixth (1990) International Conferences on AIDS. STUDY SELECTION: We identified 66 studies that included data on the behavioral effects of HIV antibody counseling and testing. By consensus of the authors, 16 of these were excluded because of small sample size or inadequate study design. DATA EXTRACTION: Studies were assessed by the authors according to methodological strength (sample selection, inclusion of appropriate comparison groups, and inclusion of statistical tests of significance). DATA SYNTHESIS: All longitudinal studies of homosexual men reported reductions in risky behavior among both tested and untested men, and a few reported greater decreases among seropositive men than among seronegative men and those untested or unaware of their serostatus. For intravenous drug users in treatment, we found reductions in intravenous drug use and sexual risk behaviors regardless of counseling and testing experience. We found little evidence for the impact of counseling and testing on pregnancy and/or pregnancy termination rates for either seropositive or seronegative high-risk women. We noted substantial risk reduction among heterosexual couples with one infected partner. Findings among other heterosexuals at increased risk were scanty and mixed. CONCLUSIONS: Further studies should specifically address the behavioral consequences of counseling and testing in various settings.