Folic acid use by women with epilepsy: Findings of the Epilepsy Birth Control Registry.

PURPOSE: To determine the prevalence and predictors of folic acid (FA) use by women with epilepsy (WWE) at risk of unintended pregnancy. METHODS: These retrospective data come from the Epilepsy Birth Control Registry (EBCR) web-based survey of 1144 WWE in the community, 18-47years, who provided demographic, epilepsy, AED, contraception, pregnancy, healthcare visits and FA data. We report prevalence and predictors of FA use in relation to risk of pregnancy (not at risk, at risk, seeking pregnancy, pregnant), demographics, seizure types and AED and contraception categories. RESULTS: 368 (47.6%) of the 773 WWE at risk of unintended pregnancy in the EBCR took FA supplement. Being at risk was a significant predictor in comparison to WWE not at risk (OR=1.464 [1.103-1.944], p=0.008). In comparison to WWE at risk, FA use trended greater for WWE actively seeking pregnancy (29/47, 61.7% v 368/773, 47.6%; p=0.0605) and was greater for pregnant WWE (17/19, 89.5% v 368/773, 47.6%; p=0.0007). Demographic predictors for WWE at risk were race (p=0.003), education (p=0.012) and income (0.043) with significantly greater FA use by Caucasians than minorities and direct correlations between FA use and levels of education and household income. Seizure type, AED use, category and dosage, polytherapy and contraceptive category were not predictors. A healthcare provider visit during the year prior to the survey was not a predictor. Prevalence of FA use was similar following visits with gynecologists - 51.7%, neurologists - 48.7% and primary care - 48.6%. FA supplementation by prescription was greater for WWE at risk on AED versus no AED (190/355, 53.5% v 3/13, 23.1%; p=0.045). CONCLUSION: Low prevalence of preconception FA use may reflect a need for more education. In addition, further research is needed to provide definitive evidence that FA reduces congenital malformations in the offspring of WWE.

Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions.

BACKGROUND: Family planning (FP) interventions aimed at reducing population growth have negligible during the last two decades in Pakistan. Innovative FP interventions that help reduce the growing population burden are the need of the hour. Marie Stopes Society--Pakistan implemented an operational research project--'Evidence for Innovating to Save Lives', to explore effective and viable intervention models that can promote healthy timing and spacing of pregnancy in rural and under-served communities of Sindh, Punjab and Khyber Pakhtunkhwa provinces of Pakistan. METHODS: We conducted a quasi-experimental (pre- and post-intervention with control arm) study to assess the effectiveness of each of the two intervention models, (1) Suraj model (meaning 'Sun' in English), which uses social franchises (SF) along with a demand-side financing (DSF) approach using free vouchers, and (2) Community Midwife (CMW) model, in promoting the use of modern contraceptive methods compared to respective controls. Baseline and endline cross-sectional household surveys were conducted, 24 months apart, by recruiting 5566 and 6316 married women of reproductive age (MWRA) respectively. We used Stata version 8 to report the net effect of interventions on outcome indicators using difference-in-differences analysis. Multivariate Cox proportional hazard regression analysis was used to assess the net effect of the intervention on current contraceptive use, keeping time constant and adjusting for other variables in the model. RESULTS: The Suraj model was effective in significantly increasing awareness about FP methods among MWRA by 14% percentage points, current contraceptive use by 5% percentage points and long term modern method--intrauterine device (IUD) use by 6% percentage points. The CMW model significantly increased contraceptive awareness by 28% percentage points, ever use of contraceptives by 7% percentage points and, IUD use by 3% percentage points. Additionally the Suraj intervention led to a 35% greater prevalence (prevalence ratio: 1.35, 95% CI: 1.22-1.50) of contraceptive use among MWRA. CONCLUSION: Suraj intervention highlights the importance of embedding subsidized FP services within the communities of the beneficiaries. The outcomes of the CMW intervention also improved the use of long-term contraceptives. These findings indicate the necessity of designing and implementing FP initiatives involving local mid-level providers to expand contraceptive coverage in under-served areas.

Quarter of a century of female sterilization in Jos, Central Nigeria.

The study was to assess the types and trend of female sterilization between January 1985 and December 2009 (25 years) in Jos, Central Nigeria. There were 25,313 new acceptors of modern contraceptive methods out of which 4,951 (19.6%) were female sterilizations. Minilaparotomy was the commonest method of female sterilization. Local anaesthesia was the commonest anaesthetic utilized. The women were mostly women of relatively older age, grandmultiparous and with large family size. The women were of mean of 38.4 years, and 60% had more than 5 children at the time of sterilization. Interval sterilization constituted 78.5% of the female sterilizations. The acceptance of female sterilization, however, has declined over the years, as acceptance of the long acting contraceptive implants increases. Female sterilization by minilaparotomy under local anaesthesia was found to be feasible, cost effective and acceptable by majority of clients, and recommended for integration into minor gynaecological procedures in our institutions.

Estudio comparativo y aleatorizado de la visita puerperal en el domicilio de la madre y en el centro de salud / Randomized comparative study of the puerperal visits in the mothers house and in the health center

Objetivo: Evaluar la efectividad, en cuanto a evolución clínica y satisfacción materna, de la visita puerperal en el domicilio y compararla con la realizada en el centro de salud. Personas, material y método: Ensayo de intervención, multicéntrico y aleatorizado, donde se comparó un grupo experimental formado por 100 mujeres que recibieron la primera asistencia posparto en el domicilio con un grupo control de 100 mujeres que tuvieron la primera visita posparto en la consulta del centro de salud. Resultados: La visita puerperal domiciliaria se asoció de manera independiente a un alto grado de satisfacción materna con la asistencia recibida (OR 10,1; IC del 95%: 3,5-29,3; p <0,001) y a un menor grado de abandono precoz de la lactancia materna (OR 15,3; IC del 95%: 1,1-205,9; p= 0,039), que fue 6 veces inferior respecto al grupo con visita puerperal en el centro de salud (1,1 frente a 6,7%; p= 0,034). El grupo de la visita puerperal domiciliaria refirió un mayor grado de información sobre sexualidad (67 frente a 33%; p <0,001) y anticoncepción (63 frentea 37%; p <0,001) en el puerperio. No se constataron diferencias en el uso de recursos sanitarios ni en otras variables clínicas. Conclusiones: Comparada con la visita puerperal en el centro de salud,la visita domiciliaria se asoció a un mayor grado de satisfacción y adquisición de conocimientos de la madre; los resultados clínicos de ambos grupos fueron comparables, excepto en el abandono precoz de la lactancia materna, inferior en el grupo que recibió la visita puerperal domiciliaria (AU)

Objective: Evaluate the effectiveness regarding to the clinical evolution and maternal satisfaction of the puerperal visit (PV) in the residence and compare it with the one done in the health center. Persons/material and method: Randomized multicentre intervention study where an experimental group of 100 women who received the first postpartum assistance in their own home, and another control group of 100 women whom received their first postpartum visit at the consultation of the health center. Results: The home PV was associated in an independent manner to a high percentage of maternal satisfaction with the assistance they received (OR 10.1; CI 95%: 3.5-29.3; p <0.001) and in a lesser degree of early abandonment of maternal breast feeding (OR 15.3; CI 95%: 1.1-205.9; p <0.039), which was six times less than the group with PV in the health center (1.1 vs 6.7% p= 0.034). The group with home PV referred a greater degree of information about sexuality (67 vs 33%;p <0.001) and anticonception (63 vs 37%; p <0.001) in the puerperal. No differences where obtained in the use of sanitary resources or in other clinical variables. Conclusions: Compared with the PV in the health center, the home PVis associated with a greater degree of satisfaction and a knowledge acquisitionby the mother, with some clinical results comparable, except for the early abandonment of breast feeding, which was favorable in thegroup with home PV (AU)

Beyond the pill: new data and options in hormonal and intrauterine contraception.

With the goal of helping clinicians facilitate contraceptive success for their patients, this Clinical Opinion provides an update regarding older hormonal and intrauterine contraceptives and details newer methods that include the progestin-releasing intrauterine system, the contraceptive patch and ring, and extended and emergency oral contraception. Last, I will look over the horizon and briefly describe potential future methods that include the single rod progestin-releasing implant, folic acid-supplemented oral contraceptives, and hormonal contraception for men.

Contraceptive use among Jamaican teenage mothers

Objective: To compare the prevalence of contraceptive use among teenage mothers who were participating, and teenage mothers who were not participating, in a program in Jamaica that had been established to deal with the country's serious problem of repeat pregnancies among adolescents. Methods: A historical cohort design was used to assess the impact that the Women's Centre of Jamaica Foundation (WCJF) Programme for Adolescent Mothers had on contraceptive use among the target population of adolescents 16 years and under who had experienced a first live birth in 1994. Results: Contraceptive use at first intercourse was found to be higher among WCJF program participants (44 percent) than among nonparticipants (37 percent), but this difference was not significant (P=0.35). Contraceptive use after first live birth was also higher among WCJF program participants (94 percent) than among nonparticipants (86 percent), and this difference was significant (P=0.04). Contraceptive prevalence at last intercourse (in 1998) did not differ between participants and nonparticipants (both 69 percent). Conclusions. Contraceptive use among this population in Jamaica was highest when the respondents' perception of vulnerability to pregnancy was most acute, that is, after the first live birth. All adolescents, both males and females, need to be educated about the importance of sustained and effective use of contraception in order to reduce the risk of unintended pregnancy and sexually transmitted diseases (AU)

The role of changes in contraceptive use in the decline of induced abortion in Turkey.

The induced abortion rate in Turkey declined from a peak of 4.5 abortions per 100 women in 1988 to 2.4 in 1998. This study examines the extent to which the decline in abortion in Turkey can be attributed to increased use of modern contraceptives. Trends in induced abortion rates and in contraceptive use are examined among Turkish women together with fertility preferences, changes in the contraceptive behavior associated with abortion, and changes in the propensity to abort unwanted pregnancies. The analysis includes a number of simulations that examine what abortion levels might be in different contraceptive-use scenarios. Results indicate that the decline in abortion is due to a decrease in the number of abortions associated with traditional method failure. This decrease is related to three factors: a shift from traditional method use to modern method use, a decline in the traditional method failure rate, and a decline in the proportion of pregnancies resulting from traditional method failures that are aborted.

Young people's contraception and sexual health: report of a local needs assessment in Staveley, North Derbyshire.

This project assessed the contraception and sexual health needs of people aged under 25 years in the small town of Staveley, UK, and sought to determine how the community family planning service could best meet these needs. One hundred and seventeen young people and 17 local professionals took part. The preferred ideal was found to be a holistic youth service based in an accessible, non-clinic setting. Clinic-based services should be more user-friendly, and various ways to achieve this were suggested. Both clients and professionals need greater awareness of all local services.

[Future prospects in contraception]. / Zukunftsperspektiven der Empfängnisverhütung.

PIP: Only 40% of the 1.2 billion couples in reproductive age have access to effective contraceptive methods, although only $3.0 per couple per year would suffice for contraception worldwide. Abortions are performed for 40-60 million women annually. More than 200,000 women die as a result of abortions, and another 500,000 die due to labor complications. Contraception for women comprises the following: 1) agents that prevent ovulation; prolonged breast feeding (98% safe contraception within the first 6 months); oral contraceptives containing estrogens and gestagens (60-80 million women use them worldwide; in 1968 the 50 g estrogen containing pill, in 1972 the micropill with 30 g of ethinyl estradiol [EE], and in 1992 the ultra-low-dose pill with 20 g of EE were introduced); and future developments (third generation progestagens, antigestagens, nonsteroidal natural substances, melatonin, the combination of gonadotropin-releasing hormone analogs and natural estrogens); 2) prevention of fertilization: mechanical methods (diaphragm, sterilization methods by laparoscopy or chemical means); chemical methods (spermicides such as nonoxynol); behavioral methods (temperature methods using refined measurement of the body temperature, cervical mucus resistance); hormonal methods (implants such as Norplant containing levonorgestrel [LNG], Implanon containing 3-ketodesogestrel, the vaginal ring [the WHO-ring and the Organon ring], the minipill with pure gestagen, one-month injection with Cyclofem), IUDs (copper-containing IUDs, LNG-containing IUDs with a Pearl Index of 0.2-0.5 and reduction of dysmenorrhea); and immunological contraception (ovum and spermatozoon antigens); 3) the prevention of implantation: hormonal methods (the morning-after pill with high-dose EE or the combination of estrogen and gestagen); insertion of an IUD up to the 6th day after coitus; immunological methods (human chorionic gonadotropin antibodies, antibodies against the zona pellucida glycoproteins, implantation inhibition through interaction with interleukin IL-1 receptor, and antibodies against specific proteins of the endometrium influencing implantation). Contraception for men consist of the condom, vasectomy, coitus interruptus, and medical inhibition of spermiogenesis (testosterone ester and gossypol).^ieng

Emergency contraception.

The term 'emergency contraception', as employed in this paper, refers to methods that are used as emergency procedures to prevent pregnancy following unprotected intercourse. Alternative, less appropriate, terms are postcoital and 'morning-after' contraception. References to postcoital preparations can be found as far back as 1500 BC in Egyptian papyri, but it was not until fairly recently that contraceptive research has been able to at least partially fulfill that need. The development of hormonal methods of emergency contraception goes back to the 1960s when the first human trials of postcoitally administered high-dose oestrogens were undertaken. Combined oestrogen- progestogen combination therapy (the so-called Yuzpe regimen) was introduced in the early 1970s, while the postcoital insertion of an intrauterine contraceptive device (IUD) for emergency contraception was first reported in 1976. Other compounds that have been tested more recently include levonorgestrel, the antiprogestogen mifepristone, and danazol. Although there is some debate about the magnitude of the protective effect, few people question the important role that emergency contraception can play in preventing unwanted pregnancy and hence maternal mortality and morbidity resulting from unsafe abortion. Given that the most often used methods of emergency contraception, namely the Yuzpe regimen and postcoital insertion of an IUD, rely on technology that has been available for some 30 years, family planning programmes that claim to be concerned with improving women's reproductive health, cannot really be excused if they do not provide emergency contraception as part of their routine services.

Fertility and family planning in Vietnam.

This report provides the first reliable statistical data on fertility patterns and the family planning program in the Socialist Republic of Vietnam. Findings are from the 1988 Demographic and Health Survey of Vietnam and the 1989 census survey. The data show that the total fertility rate has declined from over 6 children per woman in the early 1970s to under 4 in the later 1980s. Contraceptive prevalence for modern methods is estimated at 37 percent among married women of reproductive age in 1988. The average duration of breastfeeding is over 14 months; marriage is relatively late. The IUD is the most common contraceptive method and abortion is widespread. The major factors likely to influence fertility and family planning in the future are the government's population policy, improved access to modern methods of contraception, and the institution of new economic policies that are currently under way in Vietnam.

PIP: An analysis of data gathered in the 1988 Vietnam Demographic and health Survey (VNDHS) and the 1989 Census Population Five Percent Sample suggests that the country has been undergoing a process of demographic transition since the reunification of North and South Vietnam in 1975. The total fertility rate has declined from 6.1 in 1969-1974 to slightly under 4.0 in 1988-89. Factors apparently promoting this decline include changes in nuptiality patterns (in 1988, the mean age at marriage was 23.5 years and only 60% of women of reproductive age were married), a low infant mortality rate (50/1000 live births in 1988-89), growing acceptance of the government's 2-child family size norm (desired family size stands at 2.7 children among rural women and 2.3 children among urban women), and a well-organized national family planning program (54% of currently married Vietnamese women 15-44 years of age were contraceptive users in 1988). 63% of contraceptive acceptors use the IUD--the method promoted by the government's family planning effort--but there appear to be problems with the quality of IUDs provided. 45% of ever-users of clinic methods and 19% of users of supply methods utilize the commune health center and another 37% and 24%, respectively, are supplied through district hospitals. The ability of the national family planning program to offer a range of contraceptive choices has been hindered by a severe fiscal crisis in the health sector, and privatization and decentralization are receiving consideration as possible solutions. Local demographers are currently assessing whether further economic renovation is likely to support further demographic transitions or undermine policy enforcement by weakening the influence of rural cadres.

[Male contraception]. / Kontratseptsiia u muzhchin.

PIP: Various methods of contraception in men are reviewed. One of the methods of contraception is the use of hormonal agents (estrogens, androgens, antiandrogens, progestins, or their combinations), which block spermatogenesis. More advantageous is the use of nonhormonal agents (alpha-chlorhydrine, 6-chloro-6-deoxyglucose, salsosulfapyridine), which act on the process of sperm maturation in the epididymis. Plant extracts show marked contraceptive activity in men. The preparation gossypol isolated from cotton seeds and roots was found to inhibit male fertility. Various isomers of gossypol decreased sperm mobility by inhibiting the mitochondrial respiratory chain. Major side-effect of gossypol was hepatotoxicity. Glycosides isolated from the herb Tripterigium Wilfordii (TW) were found to have the antifertility activity. The antifertility effect of TW glycosides was dose- dependent: large doses were shown to inhibit spermatogenesis, while small doses were found to decrease sperm motility and viability. TW glycosides were free of toxic side-effects. Another approach to regulation of male fertility is the use of surgical methods of contraception including vasectomy. Development of less invasive and reversible surgical methods showed effectiveness of subcutaneous occlusion of vas deferens with various chemical substances (calcium chloride, p-butyl-2-cyanoacrylate). The best results were achieved with high molecular weight medical polyurethane.^ieng

The role of traditional fertility regulation in Sri Lanka.

Among the countries of South Asia, Sri Lanka, with a birth rate of 26 per 1,000, has achieved by far the lowest fertility level. The research reported here shows that at least half of all fertility control there is still practiced by means other than those offered by the national family planning program. This paper reports on an investigation carried out by the Sri Lankan Department of Census and Statistics, employing a micro-approach to demographic research, on the levels of "traditional" methods of family planning and attitudes toward the practice of both modern and traditional contraception. It is shown that knowledge of rhythm was diffused throughout society as the cost of raising children increased during a period when other methods of family planning were not easily accessible. These traditional methods were employed efficiently and their high level of continued use arises from strong cultural resistance to the pill and IUD, based upon local interpretations of how these methods function. Thus, any programmatic effort to reduce dependence on traditional family planning might well result in higher fertility levels. In addition, low fertility among Indian Tamil workers on the Tea Estates, as early as the 1950s, probably resulted from a desire (manifested by lower levels of sexual activity and some abortion) to avoid frequent pregnancies, since pregnancy interrupts work that the female Estate workers cannot afford to miss.

PIP: Among the countries of South Asia, Sri Lanka, with a birth rate of 26/1000, has achieved by far the lowest fertility level. The research reported here shows that at least 1/2 of all fertility control there is still practiced by means other than those offered by the national family planning program. The Sri Lankan Department of Census and Statistics, employing a micro-approach to demographic research, studied levels of traditional methods of family planning and attitudes toward the practice of both modern and traditional contraception. Knowledge of rhythm was diffused throughout society as the cost of raising children increased during a period when other methods of family planning were not easily accessible. Of those who practice it regularly, 2/3 report that it is a satisfactory method of fertility control, a much higher proportion than is the case with regard to any modern form of contraception. These traditional methods were employed efficiently and their high level of continued use arises from strong cultural resistance to the pill and IUD, based upon local interpretations of how these methods function. Most Sri Lankans believe that the pill has a heating effect. It is believed that the heat not only destroys the sperm but can dry or wither the womb and is likely to have a broader impact on a woman's health. Thus, any programmatic effort to reduce dependence on traditional family planning might well result in higher fertility levels. In addition, low fertility among Indian Tamil workers on the Tea Estates, as early as the 1950s, probably resulted from a desire (manifested by lower levels of sexual activity and some abortion) to avoid frequent pregnancies, since pregnancy interrupts work that the female Estate workers connort afford to miss.

Contraceptive technology in the future.

PIP: Due to the numerous adverse side effects of steroidal contraceptives which continuously arise and result in potential decreases in the benefit-to-risk ratio, new chemical and biologic strategies need to be designed and implemented to assure continued success in the contraceptive area. Novel contraceptive stragegies include both new chemical classes and their receptive biologic targets. 4 basic pharmacologic approaches subserve female contraception: inhibition of ovulation; inhibition of fertilization; inhibition of implantation; and interruption of established implantation. Many diverse compounds have been evaluated in regard to a male contraceptive, but problems of toxicity and loss of libido have made the search difficult. The problem is further complicated by the task of trying to eliminate the hundreds of millions of sperm that are constantly being produced and which are in different stages of the spermatogenic cycle. This task calls for chronic dosing and the accompanying problem of eventual liver involvement and hypertrophy of the secondary accessory sex organs. An interesting area supported by the World Health Organization is the identification of plants and the isolation of their active principles for fertility regulating purposes. The United States National Institute of Health supports 3 major and separate programs related to contraception: 1) synthesis and testing of anti-ovulatory agents; 2) synthesis and testing of male contraceptive agents; and 3) peptide antagonists of LH-RH (luteinizing hormone-releasing hormone) as ovulation inhibitors. The following categories represent areas of research that might prove fruitful: LH-RH agonists; LH-RH antagonists; non-natural synthetic products; inhibin; and plant extracts. These categories are reviewed.^ieng