Can intrauterine device removals for bleeding or pain be predicted at a one-month follow-up visit? A multivariate analysis.

From 4%-14% of intrauterine device (IUD) users have their IUD removed due to bleeding or pelvic pain in the first year of use. Past studies have analyzed whether baseline patient information can help predict such removals, but no previous analysis has examined whether information provided at the recommended 1-month follow-up visit could improve such predictions. Using data from an international multicenter randomized controlled trial, 89 women with removals for bleeding and pain after the 1-month visit were compared with 2536 continuing users. Logistic regression indicated several significant predictors of removal. Women reporting intermenstrual bleeding since last menses were nearly three times more likely to have removals for bleeding or pain (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.4-5.9). Similarly, those complaining of excessive menstrual flow were 3.5 times more likely to have removals within 12 months (95% CI 1.4-9.2). Women reporting these menstrual problems during scheduled revisits may benefit from counseling and treatment with nonsteroidal anti-inflammatory drugs (NSAID).

PIP: In the first year of use, 4-14% of IUD users have the device removed because of pelvic pain or bleeding. Identification of women at risk of removal for these reasons would enable targeted counseling and treatment, thereby reducing the frequency of removal requests. The hypothesis that problems reported at the 1-month follow-up visit can help to predict eventual IUD removal for pain or bleeding was investigated through use of data from a randomized controlled trial of IUD acceptors from 18 centers in 14 countries in Asia, Africa, and Latin America, who were followed for 1 year. The present analysis was restricted to 2536 women who received Copper T-380A or Multiload 250 IUDs. There were 89 removals for pain or bleeding during the study period. When baseline acceptor characteristics were considered, breast-feeding status was the most significant predictor of removal. Women not breast feeding at the time of IUD insertion were 2.8 times (95% confidence interval (CI), 1.5-5.2) as likely as those who were breast feeding to undergo removal for pain or bleeding in the 12 months after insertion. The following variables reported at the 1-month follow-up visit were significant predictors of removal: intermenstrual bleeding since last menses (odds ratio [OR], 1.9; 95% CI, 1.4-5.9), excessive menstrual flow (OR, 3.5; 95% CI, 1.4-9.2), and cessation of breast feeding since IUD insertion (OR, 2.2; 95% CI, 0.9-5.6). Although intermenstrual pelvic pain, spotting, and menstrual flow of more than 1 week's duration increased the risk of removal, they were not statistically significant predictors in this sample. Women who report intermenstrual bleeding or excessive menstrual flow at their 1-month follow-up visit may benefit from counseling and, in some cases, treatment with nonsteroidal anti-inflammatory drugs to reduce their risk of early IUD discontinuation.

Advance provision of oral contraceptives to family planning clients in Kenya.

OBJECTIVE: In sub-Saharan Africa, many family planning programmes do not encourage advance provision of oral contraceptives to clients who must wait until menses to initiate pill use. Since some resistance to advance provision of pills is due to provider fears that the practice may be harmful, we conducted a study in Kenya in 1997 to compare pill-taking outcomes between 20 "advance provision" clients and 280 "standard" clients. DESIGN: Prospective observational study. SETTING: Six family planning clinics in Central and Western Kenya. SUBJECTS: Women presenting as new clients at MOH family planning clinics. INTERVENTIONS: Researchers used prospective tracking to compare indicators of pill-taking success between non-menstruating clients given pills to carry home for later use and menstruating clients who began pill use immediately. MAIN OUTCOME MEASURES: Pill-taking outcomes such as side effects, compliance, knowledge, satisfaction, and a continuation proxy. RESULTS: Among clients returning for re-supply, those receiving advance provision of pills did no worse than, and often had superior outcomes to, their counterparts who started taking pills immediately after the clinic visit. CONCLUSIONS: Advance provision of pills, already practiced worldwide, is safe and feasible. Explicit mention should be made of advance provision of pills in national family planning guidance documents and training curricula in Kenya and throughout sub-Saharan Africa.

Menstruation requirements as a barrier to contraceptive access in Kenya.

BACKGROUND: In many countries, non-menstruating women are routinely denied contraceptive services even when pregnancy can easily be ruled out. OBJECTIVE: To determine whether menstruation requirements in Kenya constitute a barrier to access for potential family planning clients. DESIGN: Prospective and retrospective observational study. SETTING: Nine family planning clinics in western Kenya. SUBJECTS: Women presenting as new clients at Ministry of Health family planning clinics. INTERVENTIONS: Researchers used prospective tracking and retrospective record reviews to compare the menstrual status of women presenting for family planning services with that of women who received methods in family planning clinics. MAIN OUTCOME MEASURES: Dichotomous outcomes (menstruating versus non-menstruating women). RESULTS: During the eight-week period that tally sheets were used in the one hospital and eight health centres, 45% of the 760 women presenting for services as new clients were not menstruating (clinic range = 19%-70%). In contrast, information from clinic registers and client records in the same nine clinics showed that the (weighted) proportion of registered new clients who were menstruating was 85% (n = 102). We estimated that 78% of non-menstruating women (35% of all potential new clients) were sent away without services. CONCLUSION: For most women turned away, it is likely that pregnancy could be ruled out easily with a history and an examination. Menstruation as a pre-condition for provision of contraception wastes valuable resources and denies women their right to contraception.

[Apropos of the preliminary paraclinical evaluation of oral contraception]. / A propos du Bilan paraclinique préliminaire à la contraception orale.

As all developing countries Senegal keeps on paying a heavy tribute to, on the one hand, the high maternal mortality and morbidity, and on the other hand, infantile mortality. Family planning could have advantageous effect on health, welfare and development of all the family. Unfortunately, difficult over all socio-economical situation, lack of human resources, particularly maternal, and the coast of paraclinical exams brakes the access of population to family planning services. In this work, we tried with FHI/PSFP/Institute Pasteur to initial a prospective study who aimed to show that a good clinical exam with a complete medical interrogatory should be a good alternative to contraception preliminary paraclinical check-up.

Scanning electron microscopy of submandibular sialoliths: a preliminary report.

This report compares the scanning electron microscopic appearances of the structures in two sialoliths, one surgically removed, the other naturally exfoliated. The first exhibited the typical structure of a lamellated outer layer with an amorphous core. The core contained a large number of structures resembling calcified filamentous organisms. The second consisted of a similar outer lamella but the core contained crystal-lined spaces, amorphous matrix and an heterogeneous array of crystal shapes: there were no structures resembling organisms.

Menstruation requirements: a significant barrier to contraceptive access in developing countries.

PIP: A review of surveys from Ghana, Kenya, Cameroon, Jamaica, and Senegal suggests that the requirement that women seeking hormonal contraception and IUDs should present for family planning services when menstruating represents a significant but unrecognized barrier to contraceptive access. Non-menstruating clients are instructed to return to the family planning facility at the onset of menses and often are not provided with a provisional barrier method. The time and money involved in a return trip to the clinic may prevent poor women from making another visit and others may become pregnant while awaiting their menses. A total of 10 studies conducted in these 5 developing countries found that 41-92% of non-menstruating family planning clients were denied contraceptive services. Providers cited 4 rationales for this practice: 1) the presence of menstruation is a cheap, effective proxy for a pregnancy test; 2) methods such as the IUD and oral contraceptives are best initiated during menses; 3) menstruation requirements prevent the use of contraceptives for self-induced abortion; and 4) most clients know they should present for services when they are menstruating. Although some aspects of the menstruation requirement are rooted in a concern for women's health, the overall effect of such a restriction is to deny women the right to contraception and to place them at risk of an unwanted pregnancy. Simple checklists aimed at ruling out the possibility of pregnancy could be used in non-menstruating women.^ieng

Checklist for ruling out pregnancy among family-planning clients in primary care.

Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to nonmenstruating clients. In Kenya, a trial of a simple checklist to exclude pregnancy showed a good negative predictive value, which could improve access to service and reduce unwanted pregnancies and their sequelae.

PIP: This report presents Kenya's checklist (consisting of six simple questions) for ruling out pregnancy among family planning clients; the questions are intended to improve access to service and reduce unwanted pregnancies and their sequelae. The checklist includes questions on most recent birth, duration and frequency of breast-feeding, duration since last menstrual period, duration since last abortion or miscarriage, abstinence from sexual relations, and current contraceptive practices. The checklist was administered and followed by dipstick pregnancy tests at seven family planning clinics in order to test its validity. The checklist ruled out pregnancy for 88% of women. The checklist¿s high negative predictive value (99%) should be regarded as the relevant statistic. Widespread use of this checklist could lessen restriction to contraceptives in many countries.

Maternal mortality in Giza, Egypt: magnitude, causes, and prevention.

This article presents results from a population-based study of the magnitude and causes of maternal mortality in the Giza governorate of Egypt in 1985-86. Deaths to women in the reproductive ages were identified through the death registration system. Family members of the deceased were interviewed using the "verbal autopsy" approach. Immediate and underlying causes of death were then assessed by a medical panel. This methodology allows for the classification of multiple causes of death and is appropriate when registration of adult deaths is nearly complete, but reporting on cause of death on death certificates is poor. Of all reproductive-age deaths, 19 percent were maternal deaths. The maternal mortality ratio for Giza is estimated to be, at minimum, 126 maternal deaths per 100,000 live births. The maternal mortality rate is estimated to be, at minimum, 22 maternal deaths per 100,000 women aged 15-49, over 100 times the rate in Sweden. An average of 2.3 causes per maternal death were reported; the most common causes were postpartum hemorrhage (31 percent of cases) and hypertensive diseases of pregnancy, such as toxemia and eclampsia (28 percent of cases). Women experiencing hemorrhage, hypertensive diseases of pregnancy, or other serious complications must have easy access to hospital and maternity centers equipped for handling these conditions. Since most deliveries occur at home, many with the help of traditional birth attendants, TBAs will need training in early diagnosis, treatment, and/or effective referral of problem pregnancies.

PIP: Researchers analyzed death records of 156 women who died from obstetric causes between August 1985-August 1986 collected from 5 health sectors in Giza, Egypt to examine incidence and causes of maternal deaths. Social workers interviewed family members about circumstances of the mother's pregnancy and death (verbal autopsy approach). The maternal mortality ratio stood at 126 deaths/100,000 live births and the rate stood at 22/100,000 15-49 year old women). The cumulative risk of maternal death was at least 1 in 155 women. 50% died at a maternity center or a hospital. Remaining deaths occurred at home, another person's home, en route to the hospital, or the traditional birth attendent's (TBA) home. 35-39 year old women had the highest maternal mortality rate (40.5) while 15-19 year old women had the lowest (6.6). 24% of maternal deaths occurred to women of at least parity 7. Even though family members and the medical panel concluded that medical complications (39.1% vs. 25%) such as heart failure and hemorrhage (19.2% vs. 30.7%) were the major causes of maternal mortality, the most frequently reported causes of death as determined by the medical panel were postpartum hemorrhage (31.4%), hypertensive disease of pregnancy (27.6%), and other maternal complications (25.6%) such as prolonged and obstructed labor. This discrepancy can be explained by the fact that 70% of the mothers died of multiple causes. The researchers emphasized the need to train TBAs to diagnose problem pregnancies and to treat or refer them to hospitals or maternity centers. Health professionals used the medical profiles produced for each deceased women to formulate prevention strategies for specific cause of death strategies. The leading policy implication of this study was that most of the maternal deaths could have been prevented.