Immediate IUD insertion after second trimester abortion: implications for service delivery.

BACKGROUND: The availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Findings from a recent randomized controlled trial (RCT) in South Africa comparing immediate to delayed insertion of the copper intrauterine device (IUD) after medical abortion (MA) at 17-20 gestational weeks showed that immediate insertion resulted in higher IUD use at 6 weeks postabortion, but that expulsion rates were significantly higher than for delayed insertion. This study aims to explore barriers, facilitators, and context-specific factors relevant to the implementation of immediate IUD provision after second trimester medical abortion. METHODS: We performed a qualitative study alongside the RCT in which we conducted in-depth interviews with 14 staff providing healthcare to study participants and 24 study participants. Research questions explored barriers and facilitators to implementation of immediate IUD insertion, contraceptive decision-making, and the impact of context and supplementary trial activities on service provision. Interviews were recorded and transcribed, with translation into English if needed. We performed a triangulated thematic analysis at the level of the transcribed interview text. RESULTS: Contraceptive counselling at the abortion facility by a study nurse improved knowledge, corrected misconceptions, and increased demand for the IUD postabortion. Women expressed a clear preference for immediate insertion. Convenience, protection from pregnancy and privacy issues were paramount and women expressed preference for engagement with staff who knew their abortion history, and with whom they had an established connection. Doctors and nurses were generally in favour of immediate insertion and said it could be incorporated into standard care if women wanted this. This contrasted with the need for interventions by the research team to reinforce adherence by staff to provide contraception as allocated during the trial. CONCLUSIONS: Women and staff favour immediate IUD insertion after second trimester medical abortion, but service delivery may require structures that ensure timely insertion postabortion, continuity of care, communication that mitigates loss to follow-up and training of staff to ensure competence.

Colorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town.

BACKGROUND: Colorectal surgery is commonly performed for benign and malignant colorectal disease. The aim of this study was to describe length of stay (LOS), complications and its associated factors in patients undergoing elective colorectal surgery following implementation of an enhanced recovery after surgery (ERAS) programme in South Africa (SA). METHODS: Socio-demographic, pre- intra- and postoperative clinical details and compliance to the ERAS guidelines were recorded in all patients undergoing colorectal surgery in a private practice in Cape Town, SA. Means and standard deviations or medians and interquartile range (IQR), as appropriate, were used to describe continuous variables and frequencies and percentages for categorical variables. Bivariate and multivariate analyses using linear regression of log transformed LOS and logistic regression for development of complications were performed. RESULTS: Between 2015 and 2019, 457 patients had elective colorectal surgical procedures. The median LOS was 5 days (IQR 3-7). Pre- and intraoperative compliance was 92% and 86% respectively. In total, 203 (44%) patients developed 346 complications, of which 61% were minor. On bivariate analysis, increased intraoperative compliance was associated with a significant decrease in LOS (coefficient [ß] = 0.987, 95% confidence interval [CI] 0.984-0.991) and complications (odds ratio [OR] 0.457, 95/5 CI 0.266-0.787). For every additional 30 minutes of theatre time, irrespective of type of procedure, LOS increased by 8% and complications by 12%. On multivariate analysis, laparoscopic compared to open surgery was also associated with a shorter LOS (exp [ß] = 0.667, 95% CI 0.580-0.767 p < 0.001) and reduced complications (OR 0.457, 95% CI 0.266-0.787). CONCLUSION: Our results show that high compliance to the ERAS guidelines is possible in the private sector in SA and that a significant reduction in LOS can be achieved without placing the patient at a higher risk of complications.

Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa.

BACKGROUND: Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA). METHODS: Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors. RESULTS: Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor). CONCLUSION: We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.

Development and validation of the African Women Awareness of CANcer (AWACAN) tool for breast and cervical cancer.

BACKGROUND: Measuring factors influencing time to presentation is important in developing and evaluating interventions to promote timely cancer diagnosis, yet there is a lack of validated, culturally relevant measurement tools. This study aimed to develop and validate the African Women Awareness of CANcer (AWACAN) tool to measure awareness of breast and cervical cancer in Sub-Saharan Africa (SSA). METHODS: Development of the AWACAN tool followed 4 steps: 1) Item generation based on existing measures and relevant literature. 2) Refinement of items via assessment of content and face validity using cancer experts' ratings and think aloud interviews with community participants in Uganda and South Africa. 3) Administration of the tool to community participants, university staff and cancer experts for assessment of validity using test-retest reliability (using Intra-Class Correlation (ICC) and adjusted Kappa coefficients), construct validity (comparing expert and community participant responses using t-tests) and internal reliability (using the Kuder-Richarson (KR-20) coefficient). 4) Translation of the final AWACAN tool into isiXhosa and Acholi. RESULTS: ICC scores indicated good test-retest reliability (≥ 0.7) for all breast cancer knowledge domains and cervical cancer risk factor and lay belief domains. Experts had higher knowledge of breast cancer risk factors (p < 0.001), and cervical cancer risk factors (p = 0.003) and symptoms (p = 0.001) than community participants, but similar knowledge of breast cancer symptoms (p = 0.066). Internal reliability for breast cancer risk factors, lay beliefs and symptom and cervical cancer symptom subscales was good with KR-20 values > 0.7, and lower (0.6) for the cervical cancer risk subscale. CONCLUSION: The final AWACAN tool includes items on socio-demographic details; breast and cervical cancer symptom awareness, risk factor awareness, lay beliefs, anticipated help-seeking behaviour; and barriers to seeking care. The tools showed evidence of content, face, construct and internal validity and test-retrest reliability and are available for use in SSA in three languages.

Emtonjeni-A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study.

Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.

Self-induction of abortion among women accessing second-trimester abortion services in the public sector, Western Cape Province, South Africa: an exploratory study.

BACKGROUND: Despite South Africa's liberal abortion law permitting abortion on request in the first trimester and under restricted conditions for second-trimester pregnancies, the practice of unsafe self-induced abortion persists. However, the prevalence of this practice, the methods used and the reasons behind it are relatively under-researched. As part of a larger study seeking to improve abortion services in the Western Cape Province, we explored reports of prior attempts to self-induce abortion among women undergoing legal second-trimester abortion. OBJECTIVES: To describe the prevalence and methods of and factors related to unsuccessful attempts at self-induction of abortion by women presenting without complications and seeking second-trimester abortion at public health facilities in the Western Cape. METHODS: In a cross-sectional study from April to August 2010, 194 consenting women undergoing second-trimester abortion were interviewed by trained fieldworkers using structured questionnaires at four public sector facilities near Cape Town. RESULTS: Thirty-four women (17.5%; 95% confidence interval 12.7 - 23.4) reported an unsuccessful attempt to self-induce abortion during the current pregnancy before going to a facility for second-trimester abortion. No factors were significantly associated with self-induction, but a relatively high proportion of this small sample were unemployed and spoke an indigenous African language at home. A readily available herbal product called Stametta was most commonly used; other methods included taking tablets bought from unlicensed providers and using other herbal remedies. No use of physical methods was reported. CONCLUSIONS: The prevalence of unsafe self-induction of abortion is relatively high in the Western Cape. Efforts to inform women in the community about the availability of free services in the public sector and to educate them about the dangers of self-induction and unsafe providers should be strengthened to help address this public health issue.

The challenges of offering public second trimester abortion services in South Africa: health care providers' perspectives.

Around 25% of abortions in South Africa are performed in the second trimester. This study aimed to better understand what doctors, nurses and hospital managers involved in second trimester abortion care thought about these services and how they could be improved. Nineteen in-depth interviews with abortion-related service providers and managers in the Western Cape Province, South Africa, were undertaken. Data were analysed using a thematic analysis approach. Participants expressed resistance to the dilation and evacuation (D&E) procedure, as this required more active provider involvement. Medical abortion was preferred as it required less provider involvement in the abortion process. A shortage of providers willing to perform D&E resulted in most public sector services being outsourced to private sector doctors. Respondents noted an increased demand for services and a concomitant lack of infrastructure, physical space and personnel to respond to these demands, sometimes resulting in fragmented or poor quality care. At medical induction sites, most thought introducing the combined mifepristone-misoprostol regimen would improve service capacity, although they were concerned about cost. Improving contraceptive services was also seen as a much-needed intervention to improve care and prevent abortion. Ongoing training, including values clarification, as well as emotional support and team-building for providers are needed to ensure sustainable, high-quality second trimester abortion services.

Molar enamel thickness in the chacma baboon, Papio ursinus (Kerr 1792).

Modern humans exhibit increasing relative enamel thickness from M1 to M3. Some biomechanical (basic lever) models predict that the more distal molars in humans encounter higher occlusal forces, and it has been postulated that this provides a functional explanation for the observed gradient in relative enamel thickness. However, constrained three-dimensional models and experimental observations suggest that there is a reduction in bite force potential from M1 to M3, which would be consistent with the tendency for humans to reduce the size of the distal molars. In this regard, it has been postulated that the distal increase in enamel thickness is a consequence of crown size reduction; thus, it is unnecessary to invoke functional scenarios to explain this phenomenon. We assess these competing proposals by examining relative enamel thickness in a catarrhine primate (Papio ursinus) that exhibits crown size increase from M1 to M3. The molar row of P. ursinus is positioned relatively far forward of the temporomandibular joint, which results in the baboon being able to exert relatively greater muscle forces during posterior biting in comparison to modern humans. Thus, a significant distalward gradient of increasing enamel thickness would be expected in P. ursinus according to the hypothesis that posits it to be functionally related to bite force. The present study reveals no significant difference in relative enamel thickness along the molar row in P. ursinus. This finding lends support to the notion that the relatively thicker enamel of human distal molars is related primarily to their reduction in size. This carries potential implications for the interpretation of enamel thickness in phylogenetic reconstructions: the relatively thick molar enamel shared by modern humans and some of our fossil relatives may not be strictly homologous, in that it may result from different underlying developmental mechanisms.

Trends in optical monitoring.

Optical techniques are often used for the development of new monitoring systems for wastewater quality. The different techniques, light scattering, UV-IR spectrophotometry, fluorimetry and image analysis have given rise to recent instruments but are often limited for industrial applications. After the presentation of the principles, the advantages and drawbacks are discussed with respect to given applications.

A review of taurodontism with new data on indigenous southern African populations.

The prevalence and degree of taurodontism (enlargement of the pulp cavity) in the mandibular permanent molars of two recent population samples from southern Africa were investigated quantitatively from lateral radiographs. The degree of occlusal wear was scored and two measures of relative pulp cavity size were recorded for each tooth. There was a significant association between increased attrition and a reduction in the size of the pulp cavity when all of the teeth were considered together, but no correlation among individual molar types within each sample. In both the Zulu (n=68 individuals) and Khoisan (n=28 individuals) samples, third molars had the highest prevalence of taurodontism and first molars the lowest. The data for Zulus are similar to those recorded for other modern populations (e.g. white and black Americans, and Israelis), whereas the Khoisan data exhibit significantly higher frequencies. An increased appreciation of the distribution of this variant in modern human populations would contribute to an understanding of its possible evolutionary significance in the human fossil record.

Biomechanical beam analysis of long bones from a late 18th century slave cemetery in Cape Town, South Africa.

This study aims to quantify the physical demands of a sample of late 18th century skeletons from an unmarked burial site on Cobern Street, Cape Town, South Africa. Historical studies suggest that these individuals were either slaves or "free black" people of low socioeconomic standing. Cortical cross-sectional areas of paired humeri and tibiae from the Cobern Street collection (N = 29), a modern cadaver collection (N = 31), and a hunter-gatherer collection (N = 30) were compared by means of biomechanical beam analysis on computerized tomography scans. Results showed that the Cobern Street sample, both males and females, were closer to the modern group in total tibial cortical area and in the second moments and polar moments of cortical area, than to the hunter-gatherer group. It is assumed that these results can be explained by differences in lower limb activity. Tibial strength properties showed the hunter-gatherer peoples to be highly mobile and active walkers in comparison to the Cobern Street and modern samples. The males from the Cobern Street sample showed significantly higher values for humeral strength properties than either the hunter-gatherer or modern individuals, attesting to their status as manual laborers. The humeral cross-sectional strength properties for females were very similar between the Cobern Street and modern groups but again significantly different from the hunter-gatherer sample. The domestic chores performed by females of the recent cadaver sample may be very similar to those performed by the Cobern Street sample.

The prevalence of flexor digitorum superficialis and profundus muscle bellies beyond the proximal limit of the carpal tunnel: a cadaveric study.

A descriptive study was performed on 28 female (mean donor age, 64+/-21 years) and 26 male cadavers (mean donor age, 68+/-21 years) of mixed racial origin randomly sampled from 2 departments of anatomy. The objectives of the study were to determine the prevalence among the study population of the presence of flexor digitorum profundus and flexor digitorum superficialis muscle bellies within the proximal limit of the carpal tunnel and to investigate whether there were any sex, age, or stature differences in the study group. The female sample showed a 46% prevalence of muscle bellies in the tunnel versus only 7.8% for the male sample. The mean muscle belly distance from the proximal limit of the carpal tunnel in female cadavers was significantly smaller (p < .02) than in the male cadavers. The distribution of muscle belly distance from the tunnel, however, was found to be the same in both the male and female cadavers. In female cadavers, the majority of the mean muscle belly distances were significantly correlated with forearm length, while in the male cadavers, this was the exception rather than the rule.

Sexual dimorphism in the human corpus callosum? A comparison of methodologies.

Mid-sagittal magnetic resonance images of 104 normal individuals were analyzed to assess whether or not the corpus callosum or parts thereof is sexually dimorphic in favor of females. Subjects were 56 males and 48 females, both groups being closely age matched. The outline of the corpus callosum was divided into seven subareas, using three different orientations. A comparison was made between subareas with the divisions based on different orientations. Results showed significant differences (P < 0.05) in all cases, with one exception in females. No significant sexual dimorphism was found, with the exception of one subarea in one of the orientations which was significantly larger in males. No significant correlation was found between corpus callosal area and either cerebral hemispheric area or an estimate of cranial capacity. Relative measures, incorporating these two brain size indicators as covariates, also showed no significant sexual dimorphism. In conclusion, no sexual dimorphism of the human corpus callosum favoring females was found in this study, and it appears that inadequate sampling, differing feature orientation, and inappropriate size correction procedures may have been factors responsible for conflicting results in previous studies.