Pregnancy among sex workers participating in a condom intervention trial highlights the need for dual protection.

BACKGROUND: Little is known about pregnancy rates among sex workers (SWs) or the factors that predispose SWs to this risk. We aimed to estimate the pregnancy incidence rate among Madagascar SWs participating in an intervention trial promoting use of male and female condoms and assess the influence of various predictive factors on pregnancy risk. METHODS: SWs from two study clinics in Madagascar participated in a randomized trial to assess the effect of peer education and clinic-based counseling on use of male and female condoms and prevalence of sexually transmitted infections (STIs). Women were seen every 2 months for up to 18 months; they received structured interviews at every visit, and physical exams at baseline and every 6 months thereafter. Site staff recorded information on pregnancies during interviews; pregnancy data were then merged with trial data for this analysis. RESULTS: Of 935 SWs in the analysis population, 250 became pregnant during follow-up. The cumulative probability of pregnancy was 0.149 at 6 months and 0.227 at 12 months. Comparable proportions of nonpregnant and pregnant SWs reported using highly effective contraception at baseline (approximately 16%); these users were younger and were more consistent condom users. Method switching and discontinuation were frequent. In multivariate analysis, nonuse of effective contraceptives and any self-reported unprotected sex were associated with higher incidence of pregnancy. Approximately 51% of women delivered, 13% reported a spontaneous abortion, 13% reported an induced abortion and 23% had missing pregnancy outcomes. CONCLUSIONS: Women traditionally targeted for STI/HIV preventive interventions need more comprehensive reproductive health services. In particular, SWs could benefit from targeted family planning counseling and services.

Provider views on the acceptability of an IUD checklist screening tool.

INTRODUCTION: Family Health International developed a simple checklist to help family planning providers apply the new medical eligibility criteria (MEC) of the World Health Organization (WHO) for the use of the intrauterine device (IUD) contraceptive method. METHODS: One hundred thirty-five providers in four countries participated in focus groups to field test the checklist. Before participating in a discussion about the checklist, each provider was given a copy of the checklist, its instructions and hypothetical client scenarios. Providers used the checklist to answer questions about the client scenarios in order to determine if they understood the checklist and if they would correctly determine IUD eligibility for women in updated categories of eligibility on the basis of the checklist. RESULTS: Providers found the checklist easy to use and thought that it would enhance identification of eligible IUD users. Nevertheless, many providers relied on prior knowledge of IUD eligibility rather than the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69% of the time. CONCLUSIONS: The IUD checklist is a useful job tool for providers, but training and effective dissemination of the WHO MEC should precede its introduction to ensure that it is correctly used.

The impact of clinician education on IUD uptake, knowledge and attitudes: results of a randomized trial.

BACKGROUND: Many ministries of health worldwide would like to increase use of the intrauterine device (IUD) since it is very safe, effective and inexpensive to provide. Efforts to stimulate interest in the method have not been rigorously tested. METHODS: A randomized trial was conducted among 40 clinics in Nicaragua to test the impact of medical education on both IUD uptake and on provider knowledge/attitude toward the method. Two types of interventions were used: face-to-face medical training/education of providers and/or provision of an IUD checklist to help clinicians assess the medical eligibility of clients. RESULTS: The interventions had no impact on uptake of the IUD or on provider knowledge/attitude. CONCLUSION: While medical education and job tools (such as a checklist) for providers are indispensable for ensuring quality care, they may not be adequate to stimulate interest in the IUD on the part of clients.