- Email: [email protected]
ROUND-UP Service Delivery
Service Delivery Women’s perceptions of gynaecological morbidity in Thailand Qualitative research among rural, Lao-speaking women in Khon Khaen province, northeast Thailand, explored women’s perceptions and experience of gynaecological morbidity, lower back pain, childbearing and menstruation, as well as other symptoms culturally linked to the uterus. Although, as in many studies, the women’s self-reported symptoms did not correspond closely to biomedical diagnoses, the psychological distress caused by felt symptoms and the consequent disruption to women’s lives constitute a public health concern and need to be addressed. Although the women often turned to health care providers, they were not receiving adequate treatment but were quickly dismissed, sometimes only with painkillers. A common fear expressed by the women was that if recurrent symptoms were not adequately treated, they would progress to cervical cancer. It became apparent that health education materials from a national campaign to raise awareness about cervical cancer had fed preexisting fears of cancer and negatively influenced women’s lives. Up to 80 percent of the women in the study reported self-medicating for gynaecological symptoms, often with inappropriate antibiotics obtained from local drug sellers. This paper concludes that a more holistic understanding of the experience of gynaecological morbidity, including women’s perceptions of symptoms, local interpretations of health education messages, self-medication practices and the relationship between women and health care providers, are necessary to guide effective policy on reproductive health services. ’ I. Boonmongkon P, Nichter M, Pylypa J, 200 I. Mot Luuk problems in northeasr Thailand: why women‘> own health concerns matter as much as disease rates. Social Science and Illedicine. 53: 1095- 112.
Complete,
with misoprostol
The drug misoprostol (Cytotec) has been used to induce medical abortion both alone and in combination with mifepristone. Misoprostol is inexpensive, already licensed in many countries as a treatment for stomach ulcers and does not need to be refrigerated. Studies are ongoing in an effort to refine the dosage, to increase rates of complete abortion in early pregnancy and decrease side effects, e.g. vaginal insertion of misoprostol has been tested for doses ranging between 200 and 800 micrograms. In this trial, conducted in Cuba, the dosage used was 1000 micrograms, in order to increase the strength of uterine contractions. Three hundred women between 42 and 63 days of pregnancy who wanted to terminate their pregnancies were trained to insert five 200-microgram tablets of misoprostol into the vagina. They were also given medication to alleviate the side effects of nausea, pelvic pain, cramping and diarrhoea. If abortion had not occurred after 24 hours, the women repeated the regimen. If abortion still did not occur, the regimen was repeated again 24 hours later. All women who aborted then received an additional dose of 600 micrograms of misoprostol vaginally 24 hours after ultrasound confirmation that abortion had occurred, to ensure complete uterine evacuation. Complete abortion occurred in 93 per cent of cases. With 1000 micrograms of misoprostol cramping began after three hours, bleeding at five, and expulsion at eight hours. A poststudy questionnaire showed that the majority of women felt positively about the procedure and 94 per cent said they would use the procedure again in future if the need arose. Although side effects such as pain and nausea were common, they could be alleviated with medication. This regimen of misoprostol seems acceptable and effective for early termination of pregnancy.’ I. Carboneli JL, Rodriguez J, Aragon S et al, 2001. Vaginal misoprostol 1OOOpg for early abortion. Contraception.
190
early abortion
63:131-36.
Reproductive
Monitoring in Malawi
emergency
obstetric
services
In 1997 UNICEF, WHO and UNFPA developed guidelines for monitoring obstetric services, offering relevant process indicators which used proxy measures for maternal mortality, because counting deaths had been highly inaccurate. The Malawi Safe Motherhood Project covers half the country’s population of 5 million and was the first large project to adopt the use of the recommended indicators within routine monitoring procedures, albeit with significant adaptation. Development of the monitoring process required: a needs assessment, including identification of sources of data and definition of terms, such as for obstetric conditions; development of tools for data collection; and actual operations research. The research considered patient flow in obstetric clinics; recording of complications; and identification of maternal deaths, referral systems and the origin of patients, in order to determine the catchment populations for each service point. Subsequently, when the new monitoring system was deemed to be feasible and effective, training programmes were conducted by trainers from each district, and information was disseminated. The intention is that the Safe Motherhood information system training modules will eventually be incorporated into all basic and in-services training for maternity staff. Introduction of the indicators in Malawi was characterised by wide consultation, systematic clarification of all definitions, rigorous testing and use of already established systems. All of these steps were required to gain support and motivate staff involved in data collection and analysis.‘j2 I. Goodburn EA, Hussein J, Lema V et al, 200 1. Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system. International Journal of Gynecology and Obstetrics. 74: 105- 17. 2. Fortney J, 2001. Editor’s comment: Monitoring obstetric services: putting the UN guidelines into practice in Malawi. 1: developing the system. International
74:llR.
Journal
qf Gynecology
and Obstetrics.
Health Matters, Vol. 9, No. 18, November 2001
Testing clinical audit of emergency obstetric care in Ghana and Jamaica One of the key contributors to the high rate of maternal mortality in developing countries is poor quality emergency obstetric care at referral level. In developed countries, criterion-based clinical audit (CBCA) is now routinely used as part of quality assurance in health services. The audit team members, who are not medically qualified, screen medical records in order to determine whether the care received meets these criteria. The audit team and hospital staff then identify and implement actions to improve practice as required. In order to assessthe feasibility and effectiveness of CBCA at district hospital level, a study was conducted in two hospitals in Ghana and two in Jamaica. The types of obstetric complications chosen for audit were based on their life-threatening nature, unambiguous definition and ability to be identified from hospital registers and patient records. They included obstetric haemorrhage, eclampsia, uterine rupture, obstructed labour and sepsis. After devising working definitions for these conditions using best practice from relevant literature, an assessment was made of baseline practice. Meetings were then held with hospital staff to encourage them to identify any poor quality management of the five life-threatening complications and how to improve, including the setting of realistic targets for improvement. After 12 months of the action plan, a second round of assessments using CBCA was conducted at the hospitals. Overall, significant improvements were detected in the management of obstetric haemorrhage, eclampsia and genital tract sepsis. Although there was some improvement in care for the other two complications, the change was not statistically significant. Evidence of a continuing commitment to improving the quality of care at the four participating hospitals was reflected in the intention of staff to repeat the audit cycle until their targets were met and expand the process to other specialisms.’ 1. Wagaarachchi PT, Graham WJ, Penney GC et al, 2001. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. International Journal of Gynecology and Obstetrics. 74:119-30.
191
Round Up: Service Delivery
Perineal trauma during delivery can lead to sexual problems Women whose infants were delivered over an intact perineum reported better sexual functioning post-partum than women who experienced perineal trauma or use of obstetric instruments during delivery. This study retrospectively interviewed women in the USA whose experience after childbirth ranged from having an intact perineum or first-degree tears, through second degree perineal trauma to third or fourth degree trauma. Outcome measures were: time to resumed sexual intercourse, pain during intercourse, sexual satisfaction, sexual sensation and likelihood of achieving orgasm. At six months post-partum about a quarter of the women in all groups reported lessened sexual sensation, reduced sexual satisfaction and reduced ability to achieve orgasm compared to before delivery. Some 41 per cent reported pain during intercourse at three months and 22 per cent at six months postpartum, with the proportion rising with increased perineal trauma. Women who had had second degree trauma were 80 per cent more likely and those with third or fourth degree trauma 270 per cent more likely to report pain during intercourse at three months post-par-turn. At six months post-par-turn, the use of vacuum extraction or forceps was significantly associated with such pain. It is important to minimise the extent of perineal damage incurred during childbirth.’ 1.
Signorello LBS, Harlow BL, Chekos AK, Repke JT, 2001. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primaparous women. American Journal
ofobstetrics
and Gynecology.
184:881-90.
Cervical screening in South Africa In South Africa, where one out of every 41 women develops cervical cancer within her lifetime, the national screening policy states that every woman aged 30 and over should have a Pap smear at least three times at tenyear intervals. A 1999 assessment of screening practices, conducted in the Mitchell’s Plain District, found shortcomings in how this new policy was being implemented. Fewer Pap smears were conducted than expected, and 192
almost half of those taken lacked endocervical cells in the smear, which are necessary for an adequate reading. In addition, there was a lack of understanding of the rationale behind the programme. Furthermore, 36 per cent of women were told to have a repeat smear, which was having unforeseen cost implications. Only 14 per cent of women in the target group were being screened and there were no posters or other promotional materials about Pap smears at service delivery points. A positive finding was that 71 per cent of the women asked to have a repeat smear did so. The authors conclude that better communication, feedback and health worker training systems need to be adopted in order to ensure a high quality of service in the national screening programme.’ 1.
Smith N, Hoffman M, Moodley J, 2000. Cervical cancer: challenges in implementing a cervical cancer screening program: lessons from the Mitchell’s Plain Cervical Screening Project. Women’s Health Project Newsletter. 35: 19.
Teachin sexual health to adolescents Bangla ? esh
in
The Bangladesh Rural Advancement Committee set up an innovative reproductive and sexual health education project for adolescents in 1995. Taught by women teachers from the community, the Adolescent Reproductive Health Education (ARHE) project has been introduced through local schools and community libraries in areas with poor socio-economic conditions throughout Bangladesh. Good reproductive health knowledge is lacking among young people in Bangladesh due to strongly conservative attitudes, which particularly limit girls’ access to information on sexuality and reproduction. The ARHE curriculum addresses a wide range of topics, including physiological and emotional changes during adolescence, the process of reproduction and pregnancy, family planning, early marriage, disease prevention, substance abuse, smoking, and equality between the sexes, including a discussion of gender-based violence. Participants have reported enthusiasm for the programme, and the opportunity to talk about taboo subjects, especially menstruation in the case of young women, STIs and means of prevention for young men and ideas about roman-
Reproductive
tic love for both sexes. Conservative attitudes in rural Bangladesh may be changing, as the ARHE programme has met little resistance from community members and parents. Some problems remain, however, such as the difficulties felt by women teachers in addressing sensitive topics with adolescent boys, and frustration among adolescents that teachers continue to have inhibitions or insufficient information on HIV/AIDS and the transmission of other SITS.’ 1. Rashid SF, 2000. Providing sex education in rural Bangladesh: experiences from BRAC. Gender and Lifecycles. Oxford: Oxfam.
Condoms for adolescent
boys in Britain
Health Matters, Vol. 9, No. 78, November 2001
Mothers who provide sexual health information to adolescent girls make a difference To determine the needs and expectations of adolescent girls concerning contraceptive use as well as their attitude to healthcare providers, researchers in Belgium conducted focus group discussions with 17-year-old girls. This was followed by a quantitative survey of 700 adolescent girls. The girls’ knowledge concerning daily use and side effects of contraceptives was insufficient. However, most had good relationships with their parents and nearly 50 per cent preferred to talk to their mothers about contmceptives and sexual health. Girls who had sought advice from their mothers demonstrated safer sexual behaviour than girls who did not. Among girls who sought advice at home, 55 per cent used oral contraceptives at first intercourse, compared with 30 per cent of girls who did not talk to their mothers. Similarly, girls who spoke to their mothers were more likely to visit gynaecologists. Health care providers ~ should therefore encourage girls to talk to their mothers. The research supports better communi~ cation on the part of health care providers and parents, to ensure that appropriate information and messages are passed to adolescents.’
Britain has the highest rates of teenage pregnancy and sexually transmitted diseases among 16 to 19-year-olds in Europe, and there has been a rise in cases of chlamydia and gonorrhoea among young people. A new scheme in one London clinic encourages boys under 16 to walk in and receive condoms and advice about sex. The scheme, which organisers hope will be copied by clinics nationwide, is designed primarily for boys who are not yet sexually active. The boys are given demonstrations of condom use, advice on sexual issues, a free condom and a leaflet entitled “4Boys - a below the belt guide to the male body”. They are then ’ I. Peremans L, Van Royen P, Avonts D, Denekens J, given a registration card and once they become ~ 200 1. Doctors should not advise adolescents to abstain from sex. BA4J 322:1244a. sexually active, they can return to receive more free condoms. The average age of those coming in has been 13. The scheme was begun when ~ Use of emergency contraception in the UK staff noticed they were getting many schoolboys dropping in to their adult clinic for advice and In the UK in 1999, just over 90 per cent of saw there was clearly a need for appropriate sex women surveyed had heard of emergency hormonal contraception. Eleven per cent of them education. Most boys hear about the clinic from friends, but there are also plans to give talks in had used the emergency pill in the previous two years and one per cent had used the IUD as schools. Questions asked have included whether eating mints reduces sperm count and whether a an emergency method. Younger women were more likely than older women to use either contraceptive cap is worn on the head. More than half of boys aged 14 to 16 who visited the type of emergency contraception. A third of women aged 18-19 and a quarter of those aged clinic claimed to be sexually active. Supporters 20-24 had used the emergency pill at least once of sex education point to the Netherlands, where in the previous two years, compared with only children receive sex education from age five and four per cent of women aged 40-49.’ the teenage pregnancy rate is six times lower Over-the-counter sales of emergency contrathan in Britain.’ ceptive pills will miss opportunities for the detection of STIs and of risk reduction education. 1. Dobson R, Robbins T, 200 1. Sex clinic targets boys A letter to the BIW suggests that at the very of 11 with free condoms. Sunday Times. 5 August. 193
Round Up:Service Delivery
least, a simple leaflet should be distributed with each packet of emergency contraceptive pills, detailing the risks and giving information about local STI clinical services2 1. A third of 18- 19 year olds use the emergency pill. BMJ. 2001;323:68. 2. Stammers T, 2001. Emergency contraception from pharmacists misses opportunity [letter]. BMJ. 322:1245.
Clarifying breast cancer risk: North America Breast cancer is the most common cancer among North American women, yet studies still show that women tend to overestimate their risk of contracting the disease. Older age groups have higher rates of breast cancer, yet younger women often misinterpret the statistics that are commonly used in prevention messages. For example one message states that, on average, one in nine women will develop breast cancer at some point in their lives. In fact, women have a 50 per cent chance of developing the cancer after the age of 65 and a subsequent 60 per cent chance of surviving. The risk of women developing breast cancer in any given decade never reaches one in nine, and among younger women the risks are considerably lower. The risk of developing breast cancer for a woman in her 30s or 4Os, for instance, is 1 in 250 and 1 in 77, respectively. A few sub-groups of women are at significantly higher risk, including women with a strong family history of the disease. Yet, in their fear of breast cancer, women may discount greater risks such as that of cardiovascular disease. Inadequate understanding of the relative magnitude of different health risks could have negative impacts on health-seeking behaviour and treatment choices. As a result, the way in which information about the risk of breast cancer is conveyed to patients and the public could be improved by presenting it in a balanced way, with attention to the fact that the risk is highly dependent on age and that it no longer needs to be a fatal disease for the majority of women in most developed country settings.’ I. Phillips KA, Glcndon G, Knight JA, 1999. Putting the risk of breast cancer in perspective. New Errgland Journal
194
qffdedicine.
340:141-44.
Germany confronts cancer
high rates of breast
Germany has a high mortality from breast cancer compared to the UK and USA. Each year, there are approximately 47,000 new cases of breast cancer and 18,000 women die, although these numbers are only estimates due to incomplete cancer registration. Germany does not have a breast cancer screening programme following European guidelines, as do Sweden and the UK. Rather, mammography is used mainly for diagnosing suspicious breast lumps, and use of mammography for screening purposes is unregulated. Germany’s Health Minister has come under pressure to introduce new policy to provide every woman aged 50 to 70 with mammographic screening every other year. The federal Health Ministry, however, denied that such a policy was being prepared.’ I. Tuffs A, 2001. Germany forced to tackle high death rates from breast cancer. BMJ. 323:70.
Breast self-examination:
good idea or not?
The Canadian Task Force on Preventive Health Care has announced that physicians should not routinely teach women aged 40-69 to conduct breast self-examination on the grounds that it can do more harm than good by creating anxiety and leading to unnecessary biopsies. They also said that the usefulness of selfexamination at other ages was doubtful. Reviewing 34 years of published studies on the subject, the Task Force said that although the technique had been promoted for 30 years, only a third of women practised it monthly while even fewer did it properly. The evidence came from a series of studies conducted in the UK, China, Russia, and Canada. These findings have created confusion and anger among some women and physicians. The Canadian Breast Cancer Network stated that it would continue recommending self-examination to women.‘*2 In resource-poor settings, however, and where regular health checks are uncommon, breast self-examination may help women to catch a malignancy in the absence of screening.3,4 1. Spurgeon D, 2001. Breast self examination may do more harm than good. BMJ. 323:l lb. 2. Larkin M. 200 1. Breast self examination does more
Reproductive Health Matters, l/o/. 9, No. 18, November 2001
harm than good, says task force. Lancet. 357:2 109. Hollingsworth C, 200 1. Self examination can save lives [letter]. BMJ. 323: 1 lb. 4. Goyal V, 2001. Self breast examination [letter]. BiW. 323:l lb. 3.
Doctor-patient communication criticised by young women with breast cancer In this study, researchers held focus group discussions in the USA with women who had been diagnosed with breast cancer before the age of 50, on their reactions to the quality of patient-physician communication. Many women felt disappointed and frustrated by the approach of doctors, and reported experiencing distress at the realisation that doctors did not always adequately understand their condition and made inappropriate diagnoses and recommendations. They were angry at physicians’ paternalism and lack of respect for their concerns, and did not believe that they were receiving enough information or having their questions adequately answered. The women wanted more autonomy and a greater role in decision-making regarding their treatment. Physicians need to recognise their patients’ fears and aim for more compassionate interactions, taking into account patients’ need for detailed, clear information and the right to make their own health care choices, particularly with life-threatening conditions.’ 1.
Allen SM, Petrisek AC, Laliberte LL, 200 1. Problems in doctor-patient communication: the case of younger women with breast cancer. Critical Public Health.
11(1):39-58.
The effect of paid work on women’s in Jordan
roles
Women in Jordan increasingly have opportunities for paid employment and although they are still expected to adhere to gender-based restrictions and roles, employment has nonetheless had an impact. According to research conducted in Amman, the period of working
between
finishing
education
and
marrying has added a new life stage to women’s transition
into
adulthood.
Certain
occupations
such as teaching, manufacture of handiwork and banking are considered more appropriate than
others
for women.
Furthermore,
are expected to work primarily
women
in single-sex
environments, return home before dark and maintain a respectable reputation. Employers often co-operate with these restrictions by locating near residential neighbourhoods, offering transportation and liaising with employees’ parents to reduce the possibility of sexual harassment or inappropriate contact between the sexes. Some employed women had greater mobility and increased decision-making in the household. However, some also felt they were underpaid and at favouritism shown to male colleagues. Women’s families and the women themselves felt that women should leave paid employment after the birth of their first child to fulfil domestic responsibilities.’ 1.
Kawar M, 2000. Transitions and boundaries: research into the impact of paid work on young women’s lives in Jordan. Gender and Lifk Cycles. Oxford: Oxfam.
Free online access to medical journals Six of the world’s leading medical publishers (Blackwell, Elsevier Science, Harcourt, Kluwer, and Springer Verlag) will collaborate in a new venture to provide over 1000 medical journals free on the web to the poorest developing countries. Beginning in January 2002, a tiered pricing scheme will be introduced. The least developed countries, those with a per capita gross national product of less than US$lOOO, will be able to download journals free of charge from the web. Slightly wealthier countries will receive online access at a price that is 60-70 per cent lower than current subscription rates. The project was initiated by the BA4J World Health Organization and Soros Foundation Network. Its success is likely to be limited, however, by the lack of reliable intemet access in many of the same developing countries the offer is open to. Further, even reduced subscription prices will be beyond the means of most developing country organisations bec;ruse they need access to many journals, not just one or two. The initiative will last for at least three years, during which time its progress will be monitored.‘s2 1 Kmietowicz Z, 2001. Deal allows developing countries free access tojournals. BA4.J. 323:65. 2. Elsevier Science, 2001. WHO and Elsevier Science to provide online journal access to developing countries. Press release, July. 195
Complete,
with misoprostol
The drug misoprostol (Cytotec) has been used to induce medical abortion both alone and in combination with mifepristone. Misoprostol is inexpensive, already licensed in many countries as a treatment for stomach ulcers and does not need to be refrigerated. Studies are ongoing in an effort to refine the dosage, to increase rates of complete abortion in early pregnancy and decrease side effects, e.g. vaginal insertion of misoprostol has been tested for doses ranging between 200 and 800 micrograms. In this trial, conducted in Cuba, the dosage used was 1000 micrograms, in order to increase the strength of uterine contractions. Three hundred women between 42 and 63 days of pregnancy who wanted to terminate their pregnancies were trained to insert five 200-microgram tablets of misoprostol into the vagina. They were also given medication to alleviate the side effects of nausea, pelvic pain, cramping and diarrhoea. If abortion had not occurred after 24 hours, the women repeated the regimen. If abortion still did not occur, the regimen was repeated again 24 hours later. All women who aborted then received an additional dose of 600 micrograms of misoprostol vaginally 24 hours after ultrasound confirmation that abortion had occurred, to ensure complete uterine evacuation. Complete abortion occurred in 93 per cent of cases. With 1000 micrograms of misoprostol cramping began after three hours, bleeding at five, and expulsion at eight hours. A poststudy questionnaire showed that the majority of women felt positively about the procedure and 94 per cent said they would use the procedure again in future if the need arose. Although side effects such as pain and nausea were common, they could be alleviated with medication. This regimen of misoprostol seems acceptable and effective for early termination of pregnancy.’ I. Carboneli JL, Rodriguez J, Aragon S et al, 2001. Vaginal misoprostol 1OOOpg for early abortion. Contraception.
190
early abortion
63:131-36.
Reproductive
Monitoring in Malawi
emergency
obstetric
services
In 1997 UNICEF, WHO and UNFPA developed guidelines for monitoring obstetric services, offering relevant process indicators which used proxy measures for maternal mortality, because counting deaths had been highly inaccurate. The Malawi Safe Motherhood Project covers half the country’s population of 5 million and was the first large project to adopt the use of the recommended indicators within routine monitoring procedures, albeit with significant adaptation. Development of the monitoring process required: a needs assessment, including identification of sources of data and definition of terms, such as for obstetric conditions; development of tools for data collection; and actual operations research. The research considered patient flow in obstetric clinics; recording of complications; and identification of maternal deaths, referral systems and the origin of patients, in order to determine the catchment populations for each service point. Subsequently, when the new monitoring system was deemed to be feasible and effective, training programmes were conducted by trainers from each district, and information was disseminated. The intention is that the Safe Motherhood information system training modules will eventually be incorporated into all basic and in-services training for maternity staff. Introduction of the indicators in Malawi was characterised by wide consultation, systematic clarification of all definitions, rigorous testing and use of already established systems. All of these steps were required to gain support and motivate staff involved in data collection and analysis.‘j2 I. Goodburn EA, Hussein J, Lema V et al, 200 1. Monitoring obstetric services: putting the UN guidelines into practice in Malawi. I: developing the system. International Journal of Gynecology and Obstetrics. 74: 105- 17. 2. Fortney J, 2001. Editor’s comment: Monitoring obstetric services: putting the UN guidelines into practice in Malawi. 1: developing the system. International
74:llR.
Journal
qf Gynecology
and Obstetrics.
Health Matters, Vol. 9, No. 18, November 2001
Testing clinical audit of emergency obstetric care in Ghana and Jamaica One of the key contributors to the high rate of maternal mortality in developing countries is poor quality emergency obstetric care at referral level. In developed countries, criterion-based clinical audit (CBCA) is now routinely used as part of quality assurance in health services. The audit team members, who are not medically qualified, screen medical records in order to determine whether the care received meets these criteria. The audit team and hospital staff then identify and implement actions to improve practice as required. In order to assessthe feasibility and effectiveness of CBCA at district hospital level, a study was conducted in two hospitals in Ghana and two in Jamaica. The types of obstetric complications chosen for audit were based on their life-threatening nature, unambiguous definition and ability to be identified from hospital registers and patient records. They included obstetric haemorrhage, eclampsia, uterine rupture, obstructed labour and sepsis. After devising working definitions for these conditions using best practice from relevant literature, an assessment was made of baseline practice. Meetings were then held with hospital staff to encourage them to identify any poor quality management of the five life-threatening complications and how to improve, including the setting of realistic targets for improvement. After 12 months of the action plan, a second round of assessments using CBCA was conducted at the hospitals. Overall, significant improvements were detected in the management of obstetric haemorrhage, eclampsia and genital tract sepsis. Although there was some improvement in care for the other two complications, the change was not statistically significant. Evidence of a continuing commitment to improving the quality of care at the four participating hospitals was reflected in the intention of staff to repeat the audit cycle until their targets were met and expand the process to other specialisms.’ 1. Wagaarachchi PT, Graham WJ, Penney GC et al, 2001. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. International Journal of Gynecology and Obstetrics. 74:119-30.
191
Round Up: Service Delivery
Perineal trauma during delivery can lead to sexual problems Women whose infants were delivered over an intact perineum reported better sexual functioning post-partum than women who experienced perineal trauma or use of obstetric instruments during delivery. This study retrospectively interviewed women in the USA whose experience after childbirth ranged from having an intact perineum or first-degree tears, through second degree perineal trauma to third or fourth degree trauma. Outcome measures were: time to resumed sexual intercourse, pain during intercourse, sexual satisfaction, sexual sensation and likelihood of achieving orgasm. At six months post-partum about a quarter of the women in all groups reported lessened sexual sensation, reduced sexual satisfaction and reduced ability to achieve orgasm compared to before delivery. Some 41 per cent reported pain during intercourse at three months and 22 per cent at six months postpartum, with the proportion rising with increased perineal trauma. Women who had had second degree trauma were 80 per cent more likely and those with third or fourth degree trauma 270 per cent more likely to report pain during intercourse at three months post-par-turn. At six months post-par-turn, the use of vacuum extraction or forceps was significantly associated with such pain. It is important to minimise the extent of perineal damage incurred during childbirth.’ 1.
Signorello LBS, Harlow BL, Chekos AK, Repke JT, 2001. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primaparous women. American Journal
ofobstetrics
and Gynecology.
184:881-90.
Cervical screening in South Africa In South Africa, where one out of every 41 women develops cervical cancer within her lifetime, the national screening policy states that every woman aged 30 and over should have a Pap smear at least three times at tenyear intervals. A 1999 assessment of screening practices, conducted in the Mitchell’s Plain District, found shortcomings in how this new policy was being implemented. Fewer Pap smears were conducted than expected, and 192
almost half of those taken lacked endocervical cells in the smear, which are necessary for an adequate reading. In addition, there was a lack of understanding of the rationale behind the programme. Furthermore, 36 per cent of women were told to have a repeat smear, which was having unforeseen cost implications. Only 14 per cent of women in the target group were being screened and there were no posters or other promotional materials about Pap smears at service delivery points. A positive finding was that 71 per cent of the women asked to have a repeat smear did so. The authors conclude that better communication, feedback and health worker training systems need to be adopted in order to ensure a high quality of service in the national screening programme.’ 1.
Smith N, Hoffman M, Moodley J, 2000. Cervical cancer: challenges in implementing a cervical cancer screening program: lessons from the Mitchell’s Plain Cervical Screening Project. Women’s Health Project Newsletter. 35: 19.
Teachin sexual health to adolescents Bangla ? esh
in
The Bangladesh Rural Advancement Committee set up an innovative reproductive and sexual health education project for adolescents in 1995. Taught by women teachers from the community, the Adolescent Reproductive Health Education (ARHE) project has been introduced through local schools and community libraries in areas with poor socio-economic conditions throughout Bangladesh. Good reproductive health knowledge is lacking among young people in Bangladesh due to strongly conservative attitudes, which particularly limit girls’ access to information on sexuality and reproduction. The ARHE curriculum addresses a wide range of topics, including physiological and emotional changes during adolescence, the process of reproduction and pregnancy, family planning, early marriage, disease prevention, substance abuse, smoking, and equality between the sexes, including a discussion of gender-based violence. Participants have reported enthusiasm for the programme, and the opportunity to talk about taboo subjects, especially menstruation in the case of young women, STIs and means of prevention for young men and ideas about roman-
Reproductive
tic love for both sexes. Conservative attitudes in rural Bangladesh may be changing, as the ARHE programme has met little resistance from community members and parents. Some problems remain, however, such as the difficulties felt by women teachers in addressing sensitive topics with adolescent boys, and frustration among adolescents that teachers continue to have inhibitions or insufficient information on HIV/AIDS and the transmission of other SITS.’ 1. Rashid SF, 2000. Providing sex education in rural Bangladesh: experiences from BRAC. Gender and Lifecycles. Oxford: Oxfam.
Condoms for adolescent
boys in Britain
Health Matters, Vol. 9, No. 78, November 2001
Mothers who provide sexual health information to adolescent girls make a difference To determine the needs and expectations of adolescent girls concerning contraceptive use as well as their attitude to healthcare providers, researchers in Belgium conducted focus group discussions with 17-year-old girls. This was followed by a quantitative survey of 700 adolescent girls. The girls’ knowledge concerning daily use and side effects of contraceptives was insufficient. However, most had good relationships with their parents and nearly 50 per cent preferred to talk to their mothers about contmceptives and sexual health. Girls who had sought advice from their mothers demonstrated safer sexual behaviour than girls who did not. Among girls who sought advice at home, 55 per cent used oral contraceptives at first intercourse, compared with 30 per cent of girls who did not talk to their mothers. Similarly, girls who spoke to their mothers were more likely to visit gynaecologists. Health care providers ~ should therefore encourage girls to talk to their mothers. The research supports better communi~ cation on the part of health care providers and parents, to ensure that appropriate information and messages are passed to adolescents.’
Britain has the highest rates of teenage pregnancy and sexually transmitted diseases among 16 to 19-year-olds in Europe, and there has been a rise in cases of chlamydia and gonorrhoea among young people. A new scheme in one London clinic encourages boys under 16 to walk in and receive condoms and advice about sex. The scheme, which organisers hope will be copied by clinics nationwide, is designed primarily for boys who are not yet sexually active. The boys are given demonstrations of condom use, advice on sexual issues, a free condom and a leaflet entitled “4Boys - a below the belt guide to the male body”. They are then ’ I. Peremans L, Van Royen P, Avonts D, Denekens J, given a registration card and once they become ~ 200 1. Doctors should not advise adolescents to abstain from sex. BA4J 322:1244a. sexually active, they can return to receive more free condoms. The average age of those coming in has been 13. The scheme was begun when ~ Use of emergency contraception in the UK staff noticed they were getting many schoolboys dropping in to their adult clinic for advice and In the UK in 1999, just over 90 per cent of saw there was clearly a need for appropriate sex women surveyed had heard of emergency hormonal contraception. Eleven per cent of them education. Most boys hear about the clinic from friends, but there are also plans to give talks in had used the emergency pill in the previous two years and one per cent had used the IUD as schools. Questions asked have included whether eating mints reduces sperm count and whether a an emergency method. Younger women were more likely than older women to use either contraceptive cap is worn on the head. More than half of boys aged 14 to 16 who visited the type of emergency contraception. A third of women aged 18-19 and a quarter of those aged clinic claimed to be sexually active. Supporters 20-24 had used the emergency pill at least once of sex education point to the Netherlands, where in the previous two years, compared with only children receive sex education from age five and four per cent of women aged 40-49.’ the teenage pregnancy rate is six times lower Over-the-counter sales of emergency contrathan in Britain.’ ceptive pills will miss opportunities for the detection of STIs and of risk reduction education. 1. Dobson R, Robbins T, 200 1. Sex clinic targets boys A letter to the BIW suggests that at the very of 11 with free condoms. Sunday Times. 5 August. 193
Round Up:Service Delivery
least, a simple leaflet should be distributed with each packet of emergency contraceptive pills, detailing the risks and giving information about local STI clinical services2 1. A third of 18- 19 year olds use the emergency pill. BMJ. 2001;323:68. 2. Stammers T, 2001. Emergency contraception from pharmacists misses opportunity [letter]. BMJ. 322:1245.
Clarifying breast cancer risk: North America Breast cancer is the most common cancer among North American women, yet studies still show that women tend to overestimate their risk of contracting the disease. Older age groups have higher rates of breast cancer, yet younger women often misinterpret the statistics that are commonly used in prevention messages. For example one message states that, on average, one in nine women will develop breast cancer at some point in their lives. In fact, women have a 50 per cent chance of developing the cancer after the age of 65 and a subsequent 60 per cent chance of surviving. The risk of women developing breast cancer in any given decade never reaches one in nine, and among younger women the risks are considerably lower. The risk of developing breast cancer for a woman in her 30s or 4Os, for instance, is 1 in 250 and 1 in 77, respectively. A few sub-groups of women are at significantly higher risk, including women with a strong family history of the disease. Yet, in their fear of breast cancer, women may discount greater risks such as that of cardiovascular disease. Inadequate understanding of the relative magnitude of different health risks could have negative impacts on health-seeking behaviour and treatment choices. As a result, the way in which information about the risk of breast cancer is conveyed to patients and the public could be improved by presenting it in a balanced way, with attention to the fact that the risk is highly dependent on age and that it no longer needs to be a fatal disease for the majority of women in most developed country settings.’ I. Phillips KA, Glcndon G, Knight JA, 1999. Putting the risk of breast cancer in perspective. New Errgland Journal
194
qffdedicine.
340:141-44.
Germany confronts cancer
high rates of breast
Germany has a high mortality from breast cancer compared to the UK and USA. Each year, there are approximately 47,000 new cases of breast cancer and 18,000 women die, although these numbers are only estimates due to incomplete cancer registration. Germany does not have a breast cancer screening programme following European guidelines, as do Sweden and the UK. Rather, mammography is used mainly for diagnosing suspicious breast lumps, and use of mammography for screening purposes is unregulated. Germany’s Health Minister has come under pressure to introduce new policy to provide every woman aged 50 to 70 with mammographic screening every other year. The federal Health Ministry, however, denied that such a policy was being prepared.’ I. Tuffs A, 2001. Germany forced to tackle high death rates from breast cancer. BMJ. 323:70.
Breast self-examination:
good idea or not?
The Canadian Task Force on Preventive Health Care has announced that physicians should not routinely teach women aged 40-69 to conduct breast self-examination on the grounds that it can do more harm than good by creating anxiety and leading to unnecessary biopsies. They also said that the usefulness of selfexamination at other ages was doubtful. Reviewing 34 years of published studies on the subject, the Task Force said that although the technique had been promoted for 30 years, only a third of women practised it monthly while even fewer did it properly. The evidence came from a series of studies conducted in the UK, China, Russia, and Canada. These findings have created confusion and anger among some women and physicians. The Canadian Breast Cancer Network stated that it would continue recommending self-examination to women.‘*2 In resource-poor settings, however, and where regular health checks are uncommon, breast self-examination may help women to catch a malignancy in the absence of screening.3,4 1. Spurgeon D, 2001. Breast self examination may do more harm than good. BMJ. 323:l lb. 2. Larkin M. 200 1. Breast self examination does more
Reproductive Health Matters, l/o/. 9, No. 18, November 2001
harm than good, says task force. Lancet. 357:2 109. Hollingsworth C, 200 1. Self examination can save lives [letter]. BMJ. 323: 1 lb. 4. Goyal V, 2001. Self breast examination [letter]. BiW. 323:l lb. 3.
Doctor-patient communication criticised by young women with breast cancer In this study, researchers held focus group discussions in the USA with women who had been diagnosed with breast cancer before the age of 50, on their reactions to the quality of patient-physician communication. Many women felt disappointed and frustrated by the approach of doctors, and reported experiencing distress at the realisation that doctors did not always adequately understand their condition and made inappropriate diagnoses and recommendations. They were angry at physicians’ paternalism and lack of respect for their concerns, and did not believe that they were receiving enough information or having their questions adequately answered. The women wanted more autonomy and a greater role in decision-making regarding their treatment. Physicians need to recognise their patients’ fears and aim for more compassionate interactions, taking into account patients’ need for detailed, clear information and the right to make their own health care choices, particularly with life-threatening conditions.’ 1.
Allen SM, Petrisek AC, Laliberte LL, 200 1. Problems in doctor-patient communication: the case of younger women with breast cancer. Critical Public Health.
11(1):39-58.
The effect of paid work on women’s in Jordan
roles
Women in Jordan increasingly have opportunities for paid employment and although they are still expected to adhere to gender-based restrictions and roles, employment has nonetheless had an impact. According to research conducted in Amman, the period of working
between
finishing
education
and
marrying has added a new life stage to women’s transition
into
adulthood.
Certain
occupations
such as teaching, manufacture of handiwork and banking are considered more appropriate than
others
for women.
Furthermore,
are expected to work primarily
women
in single-sex
environments, return home before dark and maintain a respectable reputation. Employers often co-operate with these restrictions by locating near residential neighbourhoods, offering transportation and liaising with employees’ parents to reduce the possibility of sexual harassment or inappropriate contact between the sexes. Some employed women had greater mobility and increased decision-making in the household. However, some also felt they were underpaid and at favouritism shown to male colleagues. Women’s families and the women themselves felt that women should leave paid employment after the birth of their first child to fulfil domestic responsibilities.’ 1.
Kawar M, 2000. Transitions and boundaries: research into the impact of paid work on young women’s lives in Jordan. Gender and Lifk Cycles. Oxford: Oxfam.
Free online access to medical journals Six of the world’s leading medical publishers (Blackwell, Elsevier Science, Harcourt, Kluwer, and Springer Verlag) will collaborate in a new venture to provide over 1000 medical journals free on the web to the poorest developing countries. Beginning in January 2002, a tiered pricing scheme will be introduced. The least developed countries, those with a per capita gross national product of less than US$lOOO, will be able to download journals free of charge from the web. Slightly wealthier countries will receive online access at a price that is 60-70 per cent lower than current subscription rates. The project was initiated by the BA4J World Health Organization and Soros Foundation Network. Its success is likely to be limited, however, by the lack of reliable intemet access in many of the same developing countries the offer is open to. Further, even reduced subscription prices will be beyond the means of most developing country organisations bec;ruse they need access to many journals, not just one or two. The initiative will last for at least three years, during which time its progress will be monitored.‘s2 1 Kmietowicz Z, 2001. Deal allows developing countries free access tojournals. BA4.J. 323:65. 2. Elsevier Science, 2001. WHO and Elsevier Science to provide online journal access to developing countries. Press release, July. 195