Current reversible contraceptive methods: a global perspective.

Since the 1960's, there have been important gains in the efforts to make the benefits of family planning accessible to people around the world. However, prevalence of contraceptive use is still low in some areas, especially in sub-Saharan Africa. Making contraceptives accessible through good quality services should be a goal for reproductive health programs. In the absence of an ideal method of contraception which would suit every individual, there is a variety of contraceptive methods with advantages in some aspects and disadvantages in others from which people should be able to choose according to their particular characteristics and needs. Important aspects to take into consideration include effectiveness, convenience, and safety. In general, the most effective methods are more likely to have some side effects and method-related complications. However, when weighing the risks and benefits, the most effective methods have greater benefits on the health of women by protecting them better from the health risks of unwanted pregnancies. Most methods also have non-contraceptive benefits - for instance, combined oral contraceptives (COCs) provide important degrees of protection against endometrial and ovarian cancers, benign breast disease, pelvic inflammatory disease (PID), and ectopic pregnancy. They also reduce menstrual blood loss. Although barrier methods have lower effectiveness against pregnancy, their most important advantage is the protection they can provide against sexually transmitted diseases. The male condom in particular (and probably the female condom) has the special value of providing protection against HIV infection. This paper describes reversible methods of contraception including possible health risks and contraindications. Adequate counseling, however, is essential for people to make an appropriate choice of contraception and to secure safe and effective use of the method.

The mortality risk associated with hysterectomy.

To study the risks of mortality associated with hysterectomy that are specific to age, race, surgical approach, and associated conditions, we used data collected by the Commission on Professional and Hospital Activities during 1979 and 1980. Four hundred seventy-seven deaths were recorded among 317,389 women having abdominal hysterectomies and 46 deaths among 119,972 women having vaginal hysterectomies. The mortality rates for hysterectomy, standardized for age and race, were higher for procedures associated with pregnancy or cancer than for procedures not associated with these conditions (29.2, 37.8, and 6.0 per 10,000 procedures, respectively). Hysterectomies associated with pregnancy or cancer constituted 8% of all hysterectomies performed. However, 61% of all deaths occurred in women with pregnancy- or cancer-related conditions. The mortality rate associated with hysterectomy increased with age and was twice as high among black women.

Family history and the risk of breast cancer.

To investigate whether a family history of breast cancer increases a woman's risk of developing breast cancer, we analyzed data from the Centers for Disease Control's Cancer and Steroid Hormone Study. The 4,735 cases were women 20 to 54 years old with a first diagnosis of breast cancer ascertained from eight population-based cancer registries; the 4,688 controls were women selected at random from the general population of these eight areas. Compared with women without a family history of breast cancer, women who had an affected first-degree relative had a relative risk of 2.3; women with an affected second-degree relative had a relative risk of 1.5; and women with both an affected mother and sister had a relative risk of 14. The risk of breast cancer for a woman was higher if her first-degree relative had unilateral rather than bilateral breast cancer or had breast cancer detected at a younger rather than older age. For women aged 20 to 39, 40 to 44, and 45 to 54 years, the estimated annual incidence of breast cancer per 100,000 women attributable to a first-degree family history of breast cancer was 51.9, 115.1, and 138.6, respectively, and that attributable to a second-degree family history of breast cancer was 12.1, 19.2, and 92.4, respectively.

Sterilization-associated deaths: a global survey.

Except for data from several geographically limited studies, little is known globally about the number and causes of death associated with surgical sterilization. To identify clinical characteristics and problems leading to deaths related to the procedures, the International Planned Parenthood Federation ( IPPF ) and the Centers for Disease Control (CDC) in the United States collaborated in a global mail survey of 4642 physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. Fifty-five sterilization-associated deaths which occurred from January 1, 1980 to June 30, 1982 were reported. The most frequently reported causes of death were infection, anesthetic complications, and hemorrhage. There were some regional differences in the relative frequencies of these causes. Most cases did not involve surgical accident. The characteristics most frequently associated with the reported fatal procedures were: interval sterilizations, minilaparotomy incision, tubal ligation and general anesthesia. Most deaths were attributable to the surgical sterilization procedure.

PIP: To obtain information on the number and causes of deaths associated with surgical sterilization, the Centers for Disease Control (CDC) and the International Planned Parenthood Federation (IPPF) collaborated in a global mail survey of 4642 IPPF-affiliated physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. A total of 55 deaths (54 associated with tubal sterilization and 1 with vasectomy) were reported for the period January 1, 1980-June 30, 1982. The largest number of fatalities occurred in Asia (33) and Latin America (15). The median age at death was 32 years. Characteristics most frequently associated with the reported fatal procedures were interval sterilization (25 cases), minilaparotomy incision (19), tubal ligation (34), and general anesthesia (28). 38 of the tubal sterilization-associated deaths and the 1 vasectomy-related death were directly attributable to the sterilization procedure. The most frequently reported causes of death were infection (20 cases), anesthetic complications (12), and hemorrhage (8). Surgical accidents were reported for 17 of the tubal sterilization-associated fatalities. Some regional variation was noted in the relative frequencies of these causes. These data are known to reflect a substantial underreporting of sterilization-related mortality. In addition, the nonavailability of denominator data precluded estimation of the risk of death associated with surgical approach, method of tubal occlusion, timing of the sterilization procedure in relation to last pregnancy, or anesthesia. However, it can be stated that many of the deaths reported in this series could have been prevented by more adequate staff training, use of sterile equipment, and improved follow-up procedures. It is recommended that data on sterilization-related fatalities be reported to a central location to facilitate their aggregation and analysis.

Menstrual changes after tubal sterilization.

The authors used data from a multicenter prospective study of female sterilization surgery to study changes in menstrual function following tubal sterilization. Duration of menstrual bleeding, menstrual cycle length, cycle regularity, amount of menstrual bleeding, menstrual pain, and intermenstrual bleeding were examined. The authors followed 2456 women for two years after tubal sterilization surgery. Each woman served as her own control; her menstrual function at the two-year follow-up interview was compared with her menstrual function at the preoperative interview. Except for menstrual pain among women who underwent unipolar electrocoagulation procedures, there was no increase in the prevalence of adverse menstrual function after tubal sterilization. For all menstrual variables, 50% or more of women with adverse function preoperatively had an improvement by two years after tubal sterilization.

Risk of wound and pelvic infection after laparoscopic tubal sterilization: instrument disinfection versus sterilization.

To determine if disinfection, rather than sterilization, of laparoscopic equipment leads to an increase in the risk of postlaparoscopy infection, the authors analyzed data from a multicenter prospective study conducted by the Centers for Disease Control on the safety of sterilizing operations. From September 1978 through July 1981, 3903 women underwent laparoscopic tubal sterilization procedures in which the equipment was sterilized with ethylene oxide (58%) or disinfected with glutaraldehyde (42%). The overall risk of wound infection in each group was 1.5 per 100 women. The relative risk of wound infection for disinfection versus sterilization of the equipment was 0.5 when adjusted for differences in the two groups. The corresponding relative risk of pelvic infection was 1.2. These results suggest that laparoscopy equipment disinfected with glutaraldehyde is not associated with an increased risk of wound or pelvic infection compared with equipment sterilized with ethylene oxide.