Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population.

BACKGROUND: Human papillomavirus (HPV), the causative agent of cervical cancer, can be screened for using self-collected vaginal samples (self-testing). This may overcome barriers to screening for Maori women who suffer a greater burden of cervical disease than New Zealand European women. AIMS: This study aimed to explore the potential acceptability of HPV self-testing for never/under-screened (self-reported no cervical screen in 4+ years, aged 25+) Maori women by Kaupapa Maori (by, with and for Maori) mixed methods, involving hui (focus groups/interviews) and survey. MATERIALS AND METHODS: Community-based researchers ran hui with women in four regions (N = 106) and supported hui participants to collect survey data (N = 397). Healthcare providers (HCPs) were also interviewed (N = 17). Hui data were thematically analysed. Survey data were analysed by age group, rural/urban, primary health organisation (PHO) enrolment, and time since last cervical screen. RESULTS: Most survey participants were PHO-enrolled (87.15%) and attended regularly (71.79%), but did not attend regular cervical screening. A desire for bodily autonomy, including whakama (embarrassment/shyness/reticence), was the most frequently cited barrier. Three in four women reported being likely/very likely to do an HPV self-test. Nine in ten women reported being likely/very likely to attend follow up if they receive a positive HPV test result. Women and HCPs in the hui emphasised the importance of health literacy, cultural competence and empathetic support. CONCLUSION: The findings indicate that with a culturally competent introduction of HPV self-testing, many currently never/under-screened Maori women would be willing to be screened and followed up if necessary. HPV self-testing has the potential to save lives.

A global view of severe maternal morbidity: moving beyond maternal mortality.

BACKGROUND: Maternal mortality continues to be of great public health importance, however for each woman who dies as the direct or indirect result of pregnancy, many more women experience life-threatening complications. The global burden of severe maternal morbidity (SMM) is not known, but the World Bank estimates that it is increasing over time. Consistent with rates of maternal mortality, SMM rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). SEVERE MATERNAL MORBIDITY IN HIGH-INCOME COUNTRIES: Since the WHO recommended that HICs with low maternal mortality ratios begin to examine SMM to identify systems failures and intervention priorities, researchers in many HICs have turned their attention to SMM. Where surveillance has been conducted, the most common etiologies of SMM have been major obstetric hemorrhage and hypertensive disorders. Of the countries that have conducted SMM reviews, the most common preventable factors were provider-related, specifically failure to identify "high risk" status, delays in diagnosis, and delays in treatment. SEVERE MATERNAL MORBIDITY IN LOW AND MIDDLE INCOME COUNTRIES: The highest burden of SMM is in Sub-Saharan Africa, where estimates of SMM are as high as 198 per 1000 live births. Hemorrhage and hypertensive disorders are the leading conditions contributing to SMM across all regions. Case reviews are rare, but have revealed patterns of substandard maternal health care and suboptimal use of evidence-based strategies to prevent and treat morbidity. EFFECTS OF SMM ON DELIVERY OUTCOMES AND INFANTS: Severe maternal morbidity not only puts the woman's life at risk, her fetus/neonate may suffer consequences of morbidity and mortality as well. Adverse delivery outcomes occur at a higher frequency among women with SMM. Reducing preventable severe maternal morbidity not only reduces the potential for maternal mortality but also improves the health and well-being of the newborn. CONCLUSION: Increasing global maternal morbidity is a failure to achieve broad public health goals of improved women's and infants' health. It is incumbent upon all countries to implement surveillance initiatives to understand the burden of severe morbidity and to implement review processes for assessing potential preventability.

Information, support, and follow-up offered to women who experienced severe maternal morbidity.

OBJECTIVE: To determine what information, support, and follow-up were offered to women who had experienced severe maternal morbidity (SMM). METHODS: The present retrospective case review included patients who experienced SMM (admission to intensive care during pregnancy or up to 42 days postpartum) who had previously been reviewed for potential preventability as part of a nationwide New Zealand study performed between January 1 and December 31, 2014. Data were audited to ascertain documented evidence of an event debrief or explanation; referral to social support and/or mental health services; a detailed discharge letter; and a follow-up appointment with a specialist. RESULTS: Of 257 patients who experienced SMM, 23 (8.9%) were offered all four components of care, 99 (38.5%) an event debrief, 102 (39.7%) a referral to social support and/or mental health services, 148 (57.6%) a detailed discharge letter, and 131 (51.0%) a follow-up appointment. CONCLUSIONS: Many women who had experienced SMM did not receive explanatory information about their illness, an offer of psychosocial support, or a follow-up appointment prior to discharge from hospital. It is incumbent on clinicians and the maternity care system to improve these aspects of care for all women experiencing a potentially life-changing SMM event to minimize the risk and burden of long-term mental illness.

Contraception post severe maternal morbidity: a retrospective audit.

INTRODUCTION: Rapid repeat pregnancy is associated with maternal and neonatal morbidity. Effective postpartum contraception should be offered to all women, including those who experience severe acute maternal morbidity (SAMM), but little is known about contraceptive initiation in this group. Severe preexisting comorbidities with high pregnancy-related mortality risks are an important subset. This study examines contraceptive advice and prescription for SAMM cases with or without severe preexisting comorbidity. MATERIALS AND METHOD: A retrospective audit of 98 SAMM cases was conducted to identify contraceptive advice and prescription preconception (for women with severe preexisting comorbidities), antenatally and/or postnatally. This is a secondary analysis of SAMM cases audited for preventability of SAMM in four District Health Board areas (covering a third of annual births in New Zealand) during a 17-month period. Case notes and preventability audit were manually searched. RESULTS: Of 98 SAMM cases reviewed, 84 (85.7%) left hospital without a contraception prescription. Of 14 with contraception documented on discharge from hospital, 4 (4.1%) had peripartum hysterectomy, 3 (3.1%) had tubal ligation at cesarean section, 1 partner had a vasectomy booked, 1 (1%) had a Jadelle© contraceptive implant inserted and 5 (5.1%) had condom prescriptions. Of 7 women with severe preexisting comorbidity, 4 had preconception advice against conceiving. All 7 left hospital postpartum without contraceptive prescription. DISCUSSION: These results indicate substandard contraceptive care for women experiencing SAMM. All those with severe preexisting comorbidities left hospital postpartum without receiving contraception. Improvement in immediate postpartum contraceptive care for these women is advocated to avoid future morbidity and mortality.

Increasing the uptake of opportunistic chlamydia screening: a pilot study in general practice.

INTRODUCTION: Genitourinary Chlamydia trachomatis infection is common and associated with considerable personal and public health cost. Effective detection strategies are needed. AIM: To assess feasibility of an opportunistic incentivised chlamydia screening programme in general practice over six months. METHODS: This study was designed as a pilot for a randomised controlled trial in primary care. Three general practices were randomly allocated to intervention (two practices) and control groups. The intervention involved practice education, self-sample collection and practice incentives (funding and feedback) for a three-month 'active' intervention period. Feedback and education was discontinued during the second three-month period. Practice-specific nurse- or doctor-led strategies were developed for identifying, testing, treating and recalling male and female patients aged 16-24 years. The main outcome measure was the difference between the practices' chlamydia screening rates over the six months following introduction of the intervention, controlling for baseline rates from the previous year. RESULTS: Chlamydia testing rates during the year prior to the intervention ranged from 2.9% to 7.0% of practice attendances by 16-24-year-olds. The intervention practices had higher rates of screening compared with the control practice (p<0.001) at three months, but both practices reverted to pre-intervention rates by six months. The nurse-led screening strategy was more effective (35% declining to 5.5% over six months) than the doctor-led strategy (15% declining to 1.6% over six months) (p=0.04). DISCUSSION: Incentivised opportunistic chlamydia screening of 16-24-year-old patients attending their general practitioner with a programme involving practice education, feedback and self-sample collection can increase screening rates.

Poor uptake of self-sample collection kits for Chlamydia testing outside primary care.

OBJECTIVES: New strategies are needed to reach at-risk populations for Chlamydia screening. METHOD: Self-sample collection kits containing instructions and all items required for testing were developed and piloted in a three-month trial in primary care. Practice staff offered kits to young people receiving opportunistic Chlamydia screening to pass on to their 'social contacts.' RESULTS: The 'pass it on' approach failed to reach adequate numbers of youth for testing: of 67 kits distributed, three specimens were sent to the laboratory (4.5%). CONCLUSIONS: The method of kit distribution trialled here was not successful in reaching at-risk youth for testing outside the primary care setting. IMPLICATIONS: Use of self-sample collection for chlamydia testing outside healthcare settings is likely to be important for increased access to testing. The importance of chlamydia testing needs to be widely promoted and methods for kit distribution to reach at-risk youth identified.

High prevalence of Mycoplasma genitalium in women presenting for termination of pregnancy.

BACKGROUND: Sexually transmitted infections increase the risk of postoperative complications after termination of pregnancy. Mycoplasma genitalium is sexually transmitted and associated with adverse clinical outcomes in both males and females. The prevalence of M. genitalium is not yet known in New Zealand women or among women presenting for termination of pregnancy. STUDY DESIGN: This study involved prospective data collection at a public hospital clinic for termination of pregnancy. Participants were 300 under 25-year-old women presenting for termination of pregnancy. The study aimed to describe the prevalence of M. genitalium in women presenting for termination of pregnancy using real-time polymerase chain reaction (PCR) testing. Women provided a vaginal swab that was sent to the laboratory for PCR detection of M. genitalium. Data collection included age, ethnicity, previous pregnancy history, gestational age, procedure type, results of STI tests performed on referral for a termination of pregnancy (C. trachomatis, N. gonorrhoeae, T. vaginalis and bacterial vaginosis) and use of antimicrobials in the past 3 weeks. RESULTS: M. genitalium was detected in 26 women (8.7%). Rates of infection did not differ significantly by patient characteristics such as age, ethnicity or previous pregnancies. Infection with M. genitalium was not significantly associated with bacterial vaginosis or C. trachomatis infection. CONCLUSIONS: To our knowledge, this is the first prospective study designed to determine the prevalence of M. genitalium in women presenting for termination of pregnancy. Given the high proportion of cases observed in this study, further research is needed to determine the clinical significance of M. genitalium in postoperative termination of pregnancy complications.

Self-obtained vaginal swabs for PCR chlamydia testing: a practical alternative.

This study shows that given a choice, New Zealand women at high risk for sexually transmitted infections (STI) opt to provide a self-taken vaginal swab over a clinician-taken sample for STI testing. Self-obtained vaginal swabs have previously been shown to have equal sensitivity and specificity to endocervical swabs and greater sensitivity than urine for the detection of Chlamydia trachomatis by polymerase chain reaction (PCR). We suggest that self-obtained vaginal swabs should be a readily available option offered to women for chlamydia testing by PCR in New Zealand.