Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 34, Number 1, March 2008
UPDATE


BONE LOSS REVERSIBLE AFTER INJECTABLE USE

The bone loss experienced by women who use injectable progestin contraceptives is totally reversible after cessation of use, according to a study conducted among black and mixed-race clinic clients aged 18–44 in Cape Town, South Africa, between September 2002 and September 2005.1 The vast majority of the 3,487 women in the sample (97% of black women and 87% of mixed-race women) were currently using or had previously used a progestin injectable contraceptive. Using ultrasound measurements of women's left heel, researchers determined that women who were currently using an injectable had the lowest mean bone mineral density and that the density rose with increased time since last use. In fact, women who had discontinued use of the injectable for 2–3 years had approximately the same bone mineral density as women who had never used the method. The results were similar in an analysis by duration of injectable use, and in separate analyses by race (black or mixed-race) and injectable type (depot medroxyprogesterone acetate or norethisterone enanthate). The effects of injectable use on bone mineral density did not differ by age at acceptance of the method.

1. Rosenberg L et al., Bone status after cessation of use of injectable progestin contraceptives, Contraception, 2007, 76(6):425–431.

WOMEN ACCEPT LACTATIONAL AMENORRHEA, BUT FEW USE IT

The proportion of women who practice lactational amenorrhea as a method of postpartum contraception may be far lower than the proportion who intend to use it, according to a study of women who had delivered a healthy baby at a public hospital in Leon, Mexico.1 Of the 326 women who agreed to accept the method after giving birth and who completed a baseline survey and a six-month follow-up interview, only 19% actually applied the method, despite the fact that 93% reported having breast-fed their infant; the mean duration of use was 4.3 months. Sixty-six percent of new mothers who did not use the method reported that they chose not to do so because they believed the method to be ineffective. In univariate analysis, users had a significantly longer time from delivery to resumption of menstruation than did nonusers (5.5 months vs. 2.7 months); this variable remained statistically significant in multivariate analysis. The authors suggest that "an ongoing schedule of regular contacts with a health care provider, in addition to the information given post-partum, might improve actual use of the method."

1. Romero-Gutiérrez G et al., Actual use of the lactational amenorrhoea method, European Journal of Contraception and Reproductive Health Care, 2007, 12(4): 240– 244.

"SKILLED" BIRTH ATTENDANTS MAY LACK NEEDED EXPERTISE

The competence of skilled birth attendants may not be up to international clinical standards, according to a study of 1,358 providers responsible for deliveries (i.e., doctors, medical students, and professional and auxiliary nurses) at qualified basic or comprehensive emergency obstetric care facilities throughout Nicaragua.1 Overall, these providers correctly answered 62% of test questions assessing their knowledge of such topics as infection prevention and active management of third-stage labor. Results, however, varied by topic: For example, providers correctly answered 80% of questions about hemorrhage during pregnancy, but only 16% of those pertaining to infection prevention. Knowledge scores varied by type of provider as well, with doctors and medical students answering more questions correctly (72% and 68%, respectively) than professional or auxiliary nurses (57% and 51%). Similarly, in evaluations of providers' skill in using a partograph (a chart used to track the progress of a delivery) and completing certain clinical procedures (e.g., manual removal of the placenta and neonatal resuscitation), doctors were found to be the most competent, followed by medical students, professional nurses and then auxiliary nurses; however, even doctors' scores were low for certain skills, such as active management of third-stage labor (53%). The authors comment that "much effort must be directed at raising basic competencies if health personnel are to attain the proficiency and fulfill the functions anticipated by [the World Health Organization], the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives. Only then will [skilled birth attendants] be truly skilled and their deliveries become an accurate indicator of progress towards reducing maternal mortality."

1. Harvey SA et al., Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward, Bulletin of the World Health Organization, 2007, 85(10): 783–790.

STI SELF-SAMPLING AND SELF-TESTING IN SOUTH AFRICA

Self-sampling and self-testing for STIs appear to be feasible and acceptable options for women, according to a study conducted in Gugulethu, South Africa.1 Between September 2003 and August 2004, half of a sample of 626 young women were given a STI sampling and testing kit to use at home and half were given an appointment to use the same kit at a clinic. Forty-seven percent of women in the home group completed the procedures by collecting swab samples to be tested for chlamydia and gonorrhea, self-testing for trichomonas with a rapid dipstick and mailing the completed kit back to the laboratory to be analyzed; in comparison, 42% of women in the clinic group attended their clinic appointment and completed sampling and testing in the presence of a nurse. Women in the home group were more likely than those in the clinic group to complete the procedures (odds ratio, 1.7); the odds of completion increased with age and education. At six-week follow-up clinic appointments, the vast majority of women in both the home and the clinic group reported that it was easy or very easy to self-sample (86% and 96%, respectively), to follow self-testing instructions (95% and 97%) and to read the self-test results (81% and 90%). In addition, virtually all women (97%) who successfully self-sampled said that they would do it again. The authors comment that "self-sampling and self-testing are feasible and acceptable options in low-income communities such as Gugulethu." They suggest that "As rapid diagnostic tests and laboratory infrastructure improve, these technologies should be used to introduce STI screening services into a wide range of clinical and non-clinical venues to maximise programme coverage."

1. Jones HE et al., Home-based versus clinic-based self-sampling and testing for sexually transmitted infections in Gugulethu, South Africa: randomized controlled trial, Sexually Transmitted Infections, 2007, 83(7):552–557.

DISINFECTANT WIPES ARE SAFE FOR HOME DELIVERIES

Use of chlorhexidine solution as a disinfectant during home deliveries by traditional birth attendants is well-tolerated and safe, according to a study conducted in a squatter settlement of Karachi, Pakistan, between September 2005 and March 2006.1 For 103 of the 203 deliveries occurring during this period, the birth attendant cleansed the mother's birth canal and external genitalia with a solution of 0.6% chlorhexidine every four hours during labor and wiped her baby with the same solution immediately after delivery. In the other 100 deliveries, the traditional birth attendant followed the same procedure, but used a saline solution. Birth attendants did not have any difficulty implementing the chlorhexidine wipe procedure, and no mother or newborn had an adverse reaction to the application. Researchers followed up with the newborns seven, 14 and 28 days after delivery. After 28 days, 16 of those wiped with chlorhexidine had experienced skin infections, 10 had received antibiotics, 20 had been referred to a hospital by the study team and none had died; among the babies wiped with saline, those numbers were 22, 18, 26 and two. The researchers comment that "the reduction in some of the adverse neonatal outcomes suggests that a full-scale community trial of chlorhexidine vaginal and neonatal wiping is indicated."

1. Saleem S et al., Chlorhexidine vaginal and neonatal wipes in home births in Pakistan, Obstetrics & Gynecology, 2007, 110(5):977–985.

ROUTINE ANTENNAL HIV TESTING WORKS IN ZIMBABWE

Changing clinic procedures to make antenatal HIV testing routine (i.e., something that women have to opt out of instead of opt into) can substantially increase the proportion of women and infants who receive single-dose nevirapine treatment to prevent mother-to-child transmission of HIV.1 Between June and November 2005, four antenatal clinics outside of Zimbabwe's capital city of Harare began to routinely test pregnant clients for HIV, after first providing them with group or individual counseling and informing them of their right to refuse testing. During the study period, nearly 100% of pregnant clients received HIV testing, 20% of whom were HIV-positive; during the previous six months, when women had to opt into HIV testing, only 65% of pregnant clients were tested, 16% of whom were HIV-positive. In addition, there were corresponding increases in the number of HIV-positive women who were identified antenatally (926 vs. 513) and who received posttest counseling (908 vs. 487), leading to an increased number of women and infants who received single-dose nevirapine treatment. In a follow-up survey of 221 women who had previously participated in routine antenatal HIV testing, 89% said that offering routine HIV testing during pregnancy empowers women to make informed decisions about preventing mother-to-child transmission and about infant feeding. The authors comment that "Given the high antenatal HIV prevalence, implementing routine HIV testing would have a significant public health impact on the perinatal HIV epidemic in Zimbabwe and other resource- limited countries," and thus "should become the standard of care."

1. Chandisarewa W et al., Routine offer of antenatal HIV testing ("opt-out" approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe, Bulletin of the World Health Organization, 2007, 85(11):843–850.

COMMUNITY HEALTH WORKERS CAN SAFELY GIVE INJECTABLE

Community health workers in Africa can administer injectable contraceptives to women outside clinic settings as safely and effectively as can nurses and midwives in health clinics, according to a 2004 study conducted in Nakasongola, Uganda.1 Of the 945 female clients recruited to participate, 562 received an initial contraceptive injection from a trained community health worker (mostly in their home or in the home of the community health worker) and 383 from nurses and midwives at health centers. Some 777 women were interviewed by researchers 13 weeks after their initial injection, and similar proportions of clients of community health workers and clinics had received their second injection (88% and 85%, respectively). In logistic regression analysis, there was no significant difference in the odds of the two groups of clients continuing the method. In addition, there were no differences between the two client groups in satisfaction, quality of care or reported side effects. There were some differences, however, in knowledge: For example, a greater proportion of clinic clients knew that spotting is a common side effect of the injectable (33% vs. 25%), whereas a greater proportion of community health worker clients cited headaches (40% vs. 32%). The authors suggest that community health care provision of injectable contraceptives "should be scaled up in Africa and elsewhere," and add that "in doing so, programme managers should promote both quality and access through training, use of job-aids and solid logistical support systems."

1. Stanback J, Mbonye AK and Bekita M, Contraceptive injections by community health workers in Uganda: a nonrandomized community trial, Bulletin of the World Health Organization, 2007, 85(10): 768–773.