Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 36, Number 1, March 2010
UPDATE


HPV VACCINE PROTECTS WOMEN EVEN LONGER

A vaccine against the two types of human papillomavirus (HPV) most closely linked to cervical cancer effectively protects young women for more than six years against infection and the development of precancerous cervical lesions, according to an extended follow-up of an initial three-year clinical trial conducted in Brazil, Canada and the United States.1 Of the 1,113 healthy 15–25-year-old women who tested negative at baseline for HPV, half were randomized to receive the vaccine against HPV types 16 and 18, and half to receive a placebo; participants in both groups provided cervical and blood samples at six-month follow-up visits for cytological and DNA testing. The mean follow-up from the start of the study was 5.9 years; the longest follow-up was 6.4 years. Overall, the vaccine was 95% effective against infection with HPV 16 and 18, and offered substantial protection against other cancer-causing types of HPV (60% against HPV-31, and 78% against HPV-45). In addition, no women who received the vaccine developed a precancerous cervical lesion associated with HIV types 16 and 18 within the study period, for an efficacy of 100%; the efficacy of the vaccine against cervical lesions of any type was 72%. Furthermore, virtually all women (99%) in the vaccine group maintained high levels of antibodies against HPV 16 and 18 throughout the study period. The authors conclude that the vaccine provides young women with a high level of protection against HPV 16 and 18 and other types of the virus for up to 6.4 years, and expect "protection to continue for many more years." Home administration of misoprostol for a medical abortion is a safe and acceptable option for women in India, according to a study of women who chose medical abortion for early pregnancy termination at clinics in New Dehli, Lucknow, Pune and Mumbai, between January 2007 and March 2008.1 Of the 599 participants, 88% elected to self-administer oral misoprostol at home 48 hours after receiving mifepristone in the clinic, and the remainder chose to return 48 hours after receiving mifep-ristone for clinic administration of misoprostol; both groups returned to the clinic for a follow-up two weeks later. Overall, 95% administered or received misoprostol as indicated and returned on time for follow-up. There were no significant differences by group in the proportion of women lost to follow-up (4%) or the pregnancy termination success rate (89–92%); however, a greater proportion of the clinic group than of the home group required a phone call to reschedule a missed follow-up appointment (38% vs. 15%). The reasons most frequently given for choosing self-administration were convenience, fewer clinic visits and more compatibility with work or household responsibilities; the main reason mentioned for choosing clinic administration was safety. The vast majority of women (91%) reported being satisfied with their medical abortion, with no difference by group; a greater proportion of women in the home group than of those in the clinic group would choose the same protocol again if they were to have another medical abortion (95% vs. 67%).

1. Romanowski B et al., Sustained efficacy and immunogenicity of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine: analysis of a randomized placebo-controlled trial up to 6.4 years, Lancet, 2009, 374(9706):1975–1985.

MEDICAL ABORTION AT HOME IN INDIA

Home administration of misoprostol for a medical abortion is a safe and acceptable option for women in India, according to a study of women who chose medical abortion for early pregnancy termination at clinics in New Dehli, Lucknow, Pune and Mumbai, between January 2007 and March 2008.1 Of the 599 participants, 88% elected to self-administer oral misoprostol at home 48 hours after receiving mifepristone in the clinic, and the remainder chose to return 48 hours after receiving mifep-ristone for clinic administration of misoprostol; both groups returned to the clinic for a follow-up two weeks later. Overall, 95% administered or received misoprostol as indicated and returned on time for follow-up. There were no significant differences by group in the proportion of women lost to follow-up (4%) or the pregnancy termination success rate (89–92%); however, a greater proportion of the clinic group than of the home group required a phone call to reschedule a missed follow-up appointment (38% vs. 15%). The reasons most frequently given for choosing self-administration were convenience, fewer clinic visits and more compatibility with work or household responsibilities; the main reason mentioned for choosing clinic administration was safety. The vast majority of women (91%) reported being satisfied with their medical abortion, with no difference by group; a greater proportion of women in the home group than of those in the clinic group would choose the same protocol again if they were to have another medical abortion (95% vs. 67%).

1. Bracken H, Home administration of misoprostol for early medical abortion in India, International Journal of Gynecology and Obstetrics 2009, doi:10.1016/j.ijgo.2009.09.027.

IN JORDAN, FAMILY TIES AFFECT PARTNER VIOLENCE

Characteristics of women’s extended natal and marital families are associated with their likelihood of experiencing intimate partner violence, according to a study among ever-married female clients of seven Jordanian clinics conducted between February and March 2005.1 Of the 418 women surveyed, 38% reported ever experiencing violence at the hands of their husband or ex-husband; of those, 52% reported physical violence only, 24% sexual violence only and 24% both. Twenty-six percent of women had experienced violence perpetrated by a family member other than their husband, most commonly their mother-in-law or sister-in-law. In addition, 45% of women had had an extended family member—most commonly their mother-in-law or sister in-law—interfere in their relationship; of these, 46% reported that the interference had a negative effect on their marriage, 17% a positive effect and 37% no effect. Seventy-seven percent of all women reported that they could count on the support of their natal family if they needed help. In multivariate analyses, women’s risk of partner violence was positively associated with having experienced violence at the hands of a family member other than their husband and having experienced interference in their relationship with a perceived negative effect (odds ratios, 2.7 and 2.9, respectively); partner violence was negatively associated with natal family support (0.5). The authors comment that extended family relationships “deserve greater attention given the importance of the family as both a potential risk and a potential protective factor for [intimate partner violence].”

1. Clark CJ et al., The role of the extended family in women's risk of intimate partner violence in Jordan, Social Science & Medicine, 2010, 70(1):144–151.

TRADE-OFFS IN TREATING POSTPARTUM HEMORRHAGE

Misoprostol is as effective as oxytocin in treating postpartum hemorrhage among women given preventative treatment with oxytocin during labor, according to a study conducted in four countries (Burkina Faso, Egypt, Turkey and Vietnam) between August 2005 and January 2008.1 Of the 31,055 women given oxytocin prophylactically during labor, 3% experienced postpartum hemorrhage; of these, half were randomly selected to be treated with sublingual misoprostol and half with intravenous oxytocin. Nearly all women in both groups (89–90%) had their active bleeding controlled within 20 minutes of treatment; the median time to control active bleeding was 20 minutes for women in the misoprostol group and 18 minutes for those in the oxytocin group. There was no difference between groups in the proportion of women who after treatment experienced blood loss of 300ml or more or 500ml or more; however, blood loss of 1,000ml or more—experienced by 1–3% of those with hemorrhage—was more likely in the misoprostol group than in the oxytocin group (relative risk, 3.6). In addition, certain side effects, such as shivering and fever, were more likely among women in the misoprostol group (2.5 and 1.5, respectively). The authors conclude that oxytocin may be preferable to providers and policymakers concerned about side effects, whereas misprostol may be preferred because of ease of storage (unlike oxytocin, it does not need to be refrigerated) and delivery (the tablet can be administered by staff not trained or authorized to administer intravenous infusions).

1. Blum J et al., Treatment of post- partum haemorrhage with sublingual misoprostol versus oxytocin in women receiving prophylactic oxytocin: a double-blind, randomized, non-inferiority trial, Lancet, 2010, 375(9710): 217–223.

WHICH INJECTABLE USERS GAIN WEIGHT?

Use of the long-term injectable contraceptive depot-medroxy-progesterone acetate (DMPA) is associated with weight gain among normal-weight and overweight women, but not among obese women, according to a retrospective analysis conducted in Campinas, Brazil.1 From medical file data, researchers matched women who had used the injectable continuously for at least three years between 1991 and 2000 with those who had used the IUD by age and body mass index (BMI) at method adoption. The mean weight gain among injectable users after three years of method use was 4.5kg for the 226 normal-weight women (BMI less than 25kg/m2), 3.4kg for the 109 overweight (BMI 25 to 29.9kg/m2) and 1.9kg for the 44 obese women (BMI at least 30kg/m2); mean weight gains among IUD users were 1.2kg, 0.2kg and 0.6kg, respectively. In all three groups, BMI increased over the study period; however, in the normal and overweight groups, but not the obese group, BMI increased significantly more among injectable users than among IUD users. The authors conclude that "DMPA may trigger some form of metabolic alteration in normal or overweight women…that may already be present in obese women and that results in a gradual increase in weight in DMPA users."

1. Pantoja M et al., Variations in body mass index of users of depot-medroxy- progesterone acetate as a contraceptive, Contraception, 2010, 81(2):107–111.

JOB CHANGES LINKED TO PARTNER VIOLENCE

Changes in spousal employment status are associated with women's risk of being struck by their husband, according to a study conducted in Bangalore, India.1 Of the 653 married women aged 16–25 interviewed between August 2005 and February 2006 who returned for at least one 12-month follow-up visit during the 24-month study period, 57% reported at baseline that they had been hit, kicked or beaten by their husband during the prior six months. Twenty percent of women were employed at baseline; 97% reported that their husband was employed, and 60% that their husband had had difficulties finding or keeping a job in the last six months. Women who were employed at one visit had increased odds of experiencing intimate partner violence by their subsequent follow-up (odds ratio, 1.6). Those who became employed from one visit to the next had even greater odds of being struck (1.8). Furthermore, women who reported at one visit that their husband had not had employment difficulties, but said at the next that he had were more likely to have experienced violence than those whose reporting did not change (1.7); women who initially said that their husband had had employment difficulties, but later reported that he had not, were less likely to have experienced violence (0.6).

1. Krishnan S et al., Do changes in spousal employment status lead to domestic violence? Insights from a prospective study in Bangalore, India, Social Science & Medicine, 2010, 70(1): 136–143.

IN BRIEF

•Societies fail to meet the needs of women at key moments in their lives, particularly during adolescence and older age, according to Women and Health: Today’s Evidence, Tomorrow’s Agenda, published by theWorld Health Organization (WHO). The report, which includes the latest global and regional figures on the health and leading causes of death among women from birth through old age, is available at: <http://whqlibdoc.who.int/publications/2009/ 9789241563857eng.pdf>.

•Médecins Sans Frontières examines the recent faltering of international support to combat HIV/AIDS around the world in Punishing Success? Early Signs of Retreat from Commitment to HIV/AIDS Care and Treatment. The report, which discusses how underfunding threatens the progress already made and calls on the international donor community for sustained and increased commitment, can be found at: <http://www.msf.org/source/countries/africa/southafrica/ 2009/aidsreport/punishing_success.pdf>.

•More than onemillion infants die each year because they are born before 37 weeks’ gestation, according to aMarch of Dimes white paper entitled The Global and Regional Toll of Preterm Birth. The paper, which argues that strategies for reducing death and disability related to pretermbirthmust be given priority—particularly if the world is to achieveMillenniumDevelopment Goals 4 and 5—is available at <http://marchofdimes.com/files/66423_MOD-Complete.pdf>.