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O107 CONTRACEPTIVE KNOWLEDGE, ATTITUDES, AND USE IN ACCRA, GHANA
S298
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
date for achieving the Millennium Development Goals only four years away, the question of how to continue or even accelerate the decline has become more pressing. By knowing where the risk is highest as well as where the numbers of deaths are greatest, it may be possible to re-direct resources and fine-tune strategies for greater effectiveness in efforts to reduce maternal mortality Materials: We aggregate data from 38 Demographic and Health Surveys that included a maternal mortality module and were conducted in 2000 or later. We use the data on maternal deaths and the birth histories to calculate maternal mortality ratios. Methods: We calculate maternal mortality rates using the direct sisterhood method based upon seven years of recall. To obtain aggregated rates and ratios for country subgroups, we use weights derived from two factors: the weight assigned to the woman based upon the survey sampling design, and a scaling factor proportional to the size of the country relative to women- years of exposure in the survey. Using this method, we produce maternal mortality ratios, rates, and numbers of deaths by five year age groups, separately by residence, region, and overall mortality level. Results: The age pattern of maternal mortality is broadly similar across regions, type of place of residence, and overall level of mortality. A “J” shaped curve, with markedly higher risk after age 30, is evident in all groups. We find that the excess risk among adolescents is of a much lower magnitude than is generally assumed. The oldest age groups appear to be especially resistant to change. Conclusions: The largest number of maternal deaths occurs in the age groups from 20–34, largely because those are the ages at which women are most likely to give birth so efforts directed at this group would most effectively reduce the number of deaths. Yet equity considerations suggest that efforts also be directed toward those most at risk, i.e., older women and adolescents. Because women are at risk each time they become pregnant, fulfilling the substantial unmet need for contraception is a cross-cutting strategy that can address both effectiveness and equity concerns. O107 CONTRACEPTIVE KNOWLEDGE, ATTITUDES, AND USE IN ACCRA, GHANA K. Blanchard1 , N. Lince2 , R. Adanu4 , N. Douptcheva3 , A. Hill3 . 1 Ibis Reproductive Health, Cambridge, MA, United States; 2 Ibis Reproductive Health, Johannesburg, South Africa; 3 Harvard School of Public Health, Cambridge, MA, United States; 4 University of Ghana, School of Public Health, Accra, Ghana Objectives: Contraceptive prevalence in Ghana increased in the 80s and 90s, but stagnated recently; in 2008 only 17% of women used a modern contraceptive. Despite low contraceptive use, Ghana’s TFR is low (4.0) but maternal mortality is high (350/100,000). We explored demographic, knowledge and attitude, and cost facilitators and barriers to contraceptive use in Accra. Materials: We analyzed quantitative data on contraceptive attitudes and use from the Women’s Health Study in Accra (WHSA), a representative household survey fielded in 2003 and 2008/9. We also conducted a sub-study, Focused Investigations into Reproductive Health (FIRH, n = 400), in 2009 to collect data on contraceptive norms, health care seeking and use. Methods: Quantitative data was analyzed using SPSS; qualitative data was analyzed using Atlasti. We generated frequencies for the quantitative data, and compared findings by relevant demographic characteristics; we identified salient themes from qualitative focus group and in-depth interview data. Results: Contraceptive use was low; half of non-menopausal women in WHSA never used a method and over two-thirds were not currently trying to prevent pregnancy. 28% of women in FIRH reported using a method. The most commonly reported contraceptives in WHSA: male condoms (20% ever, 15% current)
and withdrawal (20% ever, 13% current). 34% of women reported ever use of periodic abstinence and 24% reported current use in WHSA; 39% of women in FIRH reported current use. Injectables (19%) and oral pills (13%) were also popular in FIRH. Contraceptive use decreased between the two surveys. Reasons for non-use of a method: don’t have a partner/not sexually active (42%), desired pregnancy (20%), or disliked side effects (11.4%). The median expenditure for a method was GHc 1.00, and median time spent was 30 minutes. Expenditure did not vary by socioeconomic status. 39% of women reported missing work and 15% were unable to complete daily tasks to get their contraceptive method. Women in focus groups preferred modern over traditional contraceptive methods; traditional methods were inconvenient and modern methods were accessible. Women shared misconceptions about modern methods and some reported negative side-effects. Conclusions: Improved information about the excellent safety profile of effective contraceptive methods could increase acceptability. Sharing stories about successful use of modern methods and the health benefits might also dispel myths and misinformation. O108 EARLY ABORTION FOR HIV+ WOMEN – IS THERE A PREFERRED METHOD? K. Blanchard1 , R. Manski1 , A. Dennis1 , D. Grossman2 . 1 Ibis Reproductive Health, Cambridge, MA, United States; 2 Ibis Reproductive Health, Oakland, CA, United States Objectives: Access to safe abortion is critical to prevent maternal mortality and morbidity among HIV+ (and HIV−) women, and to ensure their reproductive and human rights. Research shows that HIV+ women choose abortion at the same or higher rates than HIVwomen. But, few studies address clinical outcomes of abortion in HIV+ women or best practices for abortion provision. We assessed whether clinical evidence suggests a preferred method – either aspiration or medication abortion – for early abortion for HIV+ women. Materials: We conducted a review of published data on clinical outcomes of abortion among HIV+ women. Methods: From August to October 2011 we searched PubMed and a SRH/HIV database for the keyword “abortion” and the following: “HIV”, “safety”, “Africa”, “anemia”, “hemoglobin”, “side effects” and “vomit”. Due to a small number of articles with relevant data we are also reviewing literature on outcomes of similar gynecologic procedures among HIV+ women, using the keyword “HIV” and “endometriosis”, “leep” or “fibroid”, among others. We scanned the abstracts and citations of identified articles, removed any that were irrelevant, and summarized findings from the remaining studies. Results: We found 34 relevant abortion-specific articles. Three focused on clinical outcomes of aspiration abortion in HIV+ women and showed no significant differences in infectious complications by HIV-status. No studies evaluated medication abortion among HIV+ women. Some authors expressed concern about blood loss with medication abortion because HIV+ women are at higher risk of anemia, and vomiting associated with medication abortion drugs may impact efficacy of HIV medication. However, even in settings with high anemia prevalence, significant changes in hemoglobin levels with medication abortion are rare. Additionally, vomiting is a rare side effect of medication abortion; because the drug regimen is completed in two days any impact on HIV-treatment would be short-lived. We are currently reviewing data on other gynecologic procedures. Conclusions: Although scant, existing data suggest that medication and aspiration abortion are both safe and appropriate options for HIV+ women. Efforts to integrate SRH services into HIV care should include both options. Research documenting clinical experience and acceptability of medication and aspiration early abortion among HIV+ women, especially in developing countries, would be useful to inform discussions about standard of care.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S261–S530
date for achieving the Millennium Development Goals only four years away, the question of how to continue or even accelerate the decline has become more pressing. By knowing where the risk is highest as well as where the numbers of deaths are greatest, it may be possible to re-direct resources and fine-tune strategies for greater effectiveness in efforts to reduce maternal mortality Materials: We aggregate data from 38 Demographic and Health Surveys that included a maternal mortality module and were conducted in 2000 or later. We use the data on maternal deaths and the birth histories to calculate maternal mortality ratios. Methods: We calculate maternal mortality rates using the direct sisterhood method based upon seven years of recall. To obtain aggregated rates and ratios for country subgroups, we use weights derived from two factors: the weight assigned to the woman based upon the survey sampling design, and a scaling factor proportional to the size of the country relative to women- years of exposure in the survey. Using this method, we produce maternal mortality ratios, rates, and numbers of deaths by five year age groups, separately by residence, region, and overall mortality level. Results: The age pattern of maternal mortality is broadly similar across regions, type of place of residence, and overall level of mortality. A “J” shaped curve, with markedly higher risk after age 30, is evident in all groups. We find that the excess risk among adolescents is of a much lower magnitude than is generally assumed. The oldest age groups appear to be especially resistant to change. Conclusions: The largest number of maternal deaths occurs in the age groups from 20–34, largely because those are the ages at which women are most likely to give birth so efforts directed at this group would most effectively reduce the number of deaths. Yet equity considerations suggest that efforts also be directed toward those most at risk, i.e., older women and adolescents. Because women are at risk each time they become pregnant, fulfilling the substantial unmet need for contraception is a cross-cutting strategy that can address both effectiveness and equity concerns. O107 CONTRACEPTIVE KNOWLEDGE, ATTITUDES, AND USE IN ACCRA, GHANA K. Blanchard1 , N. Lince2 , R. Adanu4 , N. Douptcheva3 , A. Hill3 . 1 Ibis Reproductive Health, Cambridge, MA, United States; 2 Ibis Reproductive Health, Johannesburg, South Africa; 3 Harvard School of Public Health, Cambridge, MA, United States; 4 University of Ghana, School of Public Health, Accra, Ghana Objectives: Contraceptive prevalence in Ghana increased in the 80s and 90s, but stagnated recently; in 2008 only 17% of women used a modern contraceptive. Despite low contraceptive use, Ghana’s TFR is low (4.0) but maternal mortality is high (350/100,000). We explored demographic, knowledge and attitude, and cost facilitators and barriers to contraceptive use in Accra. Materials: We analyzed quantitative data on contraceptive attitudes and use from the Women’s Health Study in Accra (WHSA), a representative household survey fielded in 2003 and 2008/9. We also conducted a sub-study, Focused Investigations into Reproductive Health (FIRH, n = 400), in 2009 to collect data on contraceptive norms, health care seeking and use. Methods: Quantitative data was analyzed using SPSS; qualitative data was analyzed using Atlasti. We generated frequencies for the quantitative data, and compared findings by relevant demographic characteristics; we identified salient themes from qualitative focus group and in-depth interview data. Results: Contraceptive use was low; half of non-menopausal women in WHSA never used a method and over two-thirds were not currently trying to prevent pregnancy. 28% of women in FIRH reported using a method. The most commonly reported contraceptives in WHSA: male condoms (20% ever, 15% current)
and withdrawal (20% ever, 13% current). 34% of women reported ever use of periodic abstinence and 24% reported current use in WHSA; 39% of women in FIRH reported current use. Injectables (19%) and oral pills (13%) were also popular in FIRH. Contraceptive use decreased between the two surveys. Reasons for non-use of a method: don’t have a partner/not sexually active (42%), desired pregnancy (20%), or disliked side effects (11.4%). The median expenditure for a method was GHc 1.00, and median time spent was 30 minutes. Expenditure did not vary by socioeconomic status. 39% of women reported missing work and 15% were unable to complete daily tasks to get their contraceptive method. Women in focus groups preferred modern over traditional contraceptive methods; traditional methods were inconvenient and modern methods were accessible. Women shared misconceptions about modern methods and some reported negative side-effects. Conclusions: Improved information about the excellent safety profile of effective contraceptive methods could increase acceptability. Sharing stories about successful use of modern methods and the health benefits might also dispel myths and misinformation. O108 EARLY ABORTION FOR HIV+ WOMEN – IS THERE A PREFERRED METHOD? K. Blanchard1 , R. Manski1 , A. Dennis1 , D. Grossman2 . 1 Ibis Reproductive Health, Cambridge, MA, United States; 2 Ibis Reproductive Health, Oakland, CA, United States Objectives: Access to safe abortion is critical to prevent maternal mortality and morbidity among HIV+ (and HIV−) women, and to ensure their reproductive and human rights. Research shows that HIV+ women choose abortion at the same or higher rates than HIVwomen. But, few studies address clinical outcomes of abortion in HIV+ women or best practices for abortion provision. We assessed whether clinical evidence suggests a preferred method – either aspiration or medication abortion – for early abortion for HIV+ women. Materials: We conducted a review of published data on clinical outcomes of abortion among HIV+ women. Methods: From August to October 2011 we searched PubMed and a SRH/HIV database for the keyword “abortion” and the following: “HIV”, “safety”, “Africa”, “anemia”, “hemoglobin”, “side effects” and “vomit”. Due to a small number of articles with relevant data we are also reviewing literature on outcomes of similar gynecologic procedures among HIV+ women, using the keyword “HIV” and “endometriosis”, “leep” or “fibroid”, among others. We scanned the abstracts and citations of identified articles, removed any that were irrelevant, and summarized findings from the remaining studies. Results: We found 34 relevant abortion-specific articles. Three focused on clinical outcomes of aspiration abortion in HIV+ women and showed no significant differences in infectious complications by HIV-status. No studies evaluated medication abortion among HIV+ women. Some authors expressed concern about blood loss with medication abortion because HIV+ women are at higher risk of anemia, and vomiting associated with medication abortion drugs may impact efficacy of HIV medication. However, even in settings with high anemia prevalence, significant changes in hemoglobin levels with medication abortion are rare. Additionally, vomiting is a rare side effect of medication abortion; because the drug regimen is completed in two days any impact on HIV-treatment would be short-lived. We are currently reviewing data on other gynecologic procedures. Conclusions: Although scant, existing data suggest that medication and aspiration abortion are both safe and appropriate options for HIV+ women. Efforts to integrate SRH services into HIV care should include both options. Research documenting clinical experience and acceptability of medication and aspiration early abortion among HIV+ women, especially in developing countries, would be useful to inform discussions about standard of care.