Round Up: Service delivery

Round Up: Service delivery © 2010 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2010;18(35):186–191 0968-8080/10 $ – see fr...

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© 2010 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2010;18(35):186–191 0968-8080/10 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 1 0 ) 3 5 5 1 4 - 5


Service delivery Cervical cancer screening approaches in low-resource settings In 1999, five international health organisations came together to create the Alliance for Cervical Cancer Prevention (ACCP). On the basis of recent studies and earlier research conducted in 20 African, Asian and Latin American countries, the ACCP partners have summarised key findings and recommendations for effective cervical screening and treatment programmes in lowresource settings. The optimal age-group for screening to achieve the greatest public health impact is 30–39. Although cytology-based screening using Pap smears is effective in developed countries, sustaining high-quality programmes in low-resource settings is difficult and efforts should be directed to more affordable strategies for which quality can be assured. Visual inspection with acetic acid (VIA) or HPV DNA testing followed by cryotherapy at the same visit is the most efficient and effective strategy and can be carried out by physicians, nurses, midwives and other nonphysicians. Cryotherapy is a safe way of treating pre-cancerous cervical lesions and results in cure rates of at least 85%. Unless cervical cancer is suspected, the routine use of an intermediate diagnostic step, such as colposcopy, is not efficient and may reduce programme success and increase cost. Priorities for the future include ensuring that HPV DNA tests and effective cryotherapy units are available at low cost, accurate information is available, community organisations and women are consulted about services, and effective training and continuous quality improvement are available.1 1. Sherris J, Wittet S, Kleine A, et al. Evidence-based, alternative cervical cancer screening approaches in low-resource settings. International Perspectives on Sexual and Reproductive Health 2009;35(3):147–52.

Should boys be vaccinated against HPV – yes The human papillomavirus (HPV) vaccine is licensed for boys as well as girls in several coun186

tries. Disease simulation models on 12-year-olds in the US were used to assess the cost-effectiveness of including boys in a routine HPV vaccination programme for girls. With 75% coverage and an assumption of complete, lifelong vaccine efficacy, routine HPV vaccination of 12-year-old girls was consistently less than $50,000 per qualityadjusted life-year (QALY) gained, compared with screening alone. Including boys in the programme for girls resulted in higher costs that generally exceeded $100,000 per QALY − the conventional threshold of good value for money − even under favourable conditions of vaccine protection and health benefits. Uncertainty still exists in many areas that can either strengthen or attenuate these findings.1 An editorial suggests that where the uptake of HPV vaccination is poor in girls, vaccination of boys may become better value by improving herd immunity. Vaccination of boys can also be advocated on ethical grounds, to promote equality and social responsibility. Targeting young women for vaccination and screening older women in developing countries − where 80% of the annual cervical cancer cases occur − would have a bigger effect than widespread HPV vaccination of young men in developed countries, however. The best policy is to ensure that pre-adolescent girls are vaccinated worldwide.2 A letter in response claims that the paper and editorial ignored some male-specific HPV-related diseases that should be considered in future costeffectiveness analyses. Firstly, by vaccinating girls only, men would remain carriers and could transmit the virus to non-vaccinated women and men. Secondly, the percentage of HPV-related diseases is high in some groups of men – for example, oropharyngeal cancer, conjunctival squamous cancer, genital warts, and anal and penile cancers in homosexual, bisexual, and HIV-positive men. Thirdly, HPV in ejaculated sperm may be associated with reduced sperm motility and male infertility, which often needs to be treated with expensive assisted reproduction techniques. Lastly,

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HPV was recently found in six of 100 cryopreserved semen samples from men with testicular cancer or infertility, which would have been used for assisted reproduction if not found.3 1. Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys in a human papillomavirus vaccination programme in the United States. BMJ 2009;339:b3884. 2. Castle PE, Scarinci I. Should HPV vaccine be given to men? BMJ 2009;339:b4127. 3. Foresta C, Felin A, Garolla A. What about male specific HPV related diseases? BMJ 2009; 339:b4514.

HPV vaccination leads to rapid decline in genital warts, Australia The number of young women presenting with new cases of genital warts in Australia has declined since the introduction of the national human papillomavirus vaccination programme. A retrospective study examined the proportion of new patients with genital warts attending Melbourne Sexual Health Centre from January 2004 to December 2008. Australia has offered the quadrivalent HPV vaccine, Gardasil, free to 12–18 year old girls in schools since April 2007, and to women aged 26 and younger in general practices since July 2007. Take-up rates have been approximately 70%. Gardasil targets HPV types 6, 11, 16, and 18. Types 6 and 11 are associated with genital warts, and types 16 and 18 with the development of cervical cancer. A total of 36,055 new patients attended the clinic and genital warts were diagnosed in 3,826 (10.6%). The proportion of women under 28 years diagnosed with warts decreased by 25.1% each quarter in 2008, which was significantly different from the 1.8% increase per quarter from 2004 to 2007 (p<0.001). Women under 28 made up about 13% of patients diagnosed as having genital warts before 2008, but only 6.6% in 2008. The only other group that saw a decline in genital warts was heterosexual men, among whom new diagnoses fell by 5% each quarter in 2008 (p=0.031). The data suggest that a rapid and marked reduction in genital wart incidence may be achievable through an HPV vaccination programme targeting adolescents and young women, and supports some benefit being conferred on heterosexual men. These results are important for countries deciding

between the bivalent vaccine that does not protect against warts and the quadrivalent vaccine.1,2 1. Fairley CK, Hocking JS, Gurrin LC, et al. Rapid decline in presentations of genital warts after the implementation of a national quadrivalent human papillomavirus vaccination programme for young women. Sexually Transmitted Infections 2009;85:499–502. 2. Kmietowicz Z. Australian cervical cancer vaccination leads to rapid decline in genital warts. BMJ 2009; 339:b2421.

Long-term effects of genital warts on quality of life This study shows that genital warts may have quality of life effects for a long time after clearance. This qualitative study with six former genital warts patients used a semi-structured interview guide that included questions and issues that were identified in two previous studies of the quality of life of heterosexual and homosexual genital warts patients. The participants were persistently worried about genital warts recurrence, about being prone to develop anogenital cancers and about the continual, negative effects on their sex and love lives. The women in particular suffered from permanent damage to their genital mucosa due to laser treatment for genital warts. The results of this study underline the need to disseminate knowledge about genital warts in order to promote preventive measures such as condoms and quadrivalent HPV vaccination. Patients with genital warts have a considerable need for detailed information about the disease and for being involved in the choice of their treatment. Finally, persisting worries about recurrence and ano-genital cancers should be addressed when communicating with patients.1 1. Mortensen GL. Long-term quality of life effects of genital warts – a follow-study. Danish Medical Bulletin 2010;57(4):A4140.

Cervical screening and HPV infection in lesbian and bisexual women Patterns of sexually transmitted disease among lesbian women is quite different from heterosexual women, and little is known about lesbians’ 187

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participation in cervical screening programmes. This review, commissioned by the UK National Health Service Cervical Screening Programme, synthesises data from 2,290 existing papers in 11 electronic databases related to screening for cervical cancer and transmission of human papillomavirus (HPV) among lesbian and bisexual women. The prevalence of HPV in lesbian and bisexual women ranged from 3.3% to 30% in the studies. Among women with no history of heterosexual sex the prevalence was 19%. Lesbian and bisexual women may contract HPV through sex with men or through sex with a woman who has had previous heterosexual sex. It can be transmitted during oral sex between women, vaginal penetration with fingers, sharing sex toys or skinto-skin contact. Time intervals between screening among lesbians were greater than among heterosexual women. Lesbian and bisexual women were up to ten times less likely to have had a test in the past three years. Women who had never had sex with men were less likely to be screened than those who had, and the prevalence among lesbian/ bisexual women who had never undergone screening ranged from 12% to 17% in UK studies. Lesbians considered themselves at lower risk of cervical cancer than bisexual or heterosexual women; this assumption is challenged by these data. The report calls for more targeted advice on HPV and cervical cancer screening for lesbians.1,2 1. Moszynski P. Cervical cancer virus can be transmitted through same sex relationships, report warns. BMJ 2009;339:b5667. 2. Fish J. Cervical screening in lesbian and bisexual women: a review of the worldwide literature using systematic methods. De Montfort University 2009. At:

Low priority for infertility services in Brazil’s public health sector This cross-sectional study assessed the availability of public sector infertility services, including assisted reproduction technology (ART), in Brazil. Between June 2008 and June 2009, telephone interviews were conducted with 24 of the 26 authorities from the State Health Secretariats and authorities from the Federal District and 39 of the 42 authorities from the Municipal Health Secretariats, including 25 from the 26 state capi188

tals and 14 from the 16 other cities with more than 500,000 inhabitants. 26 directors of referral centres and teaching hospitals providing government-funded infertility care and ART were also interviewed. In 19/25 states (76%) and 26/39 cities (66.7%), no infertility treatment was available free of charge. No ART was available at 84% and 97% of the state and municipal levels, respectively. In contrast, 56 infertility clinics were registered in the private sector. The most common reason for lack of services at the state and municipal levels was “lack of any political decision to implement them”, followed by “lack of human and financial resources”. When ART was available, barriers to access included the fact that patients needed to purchase medication, and there was a more than one-year waiting list. Lack of political commitment results in inequity in the access of low-income couples in Brazil to infertility treatment.1 1. Makuch MY, Petta CA, Osis MJD, et al. Low priority level for infertility services within the public health sector: a Brazilian case study. Human Reproduction 2010;25(2):430–35.

Crossing borders for infertility treatment in Belgium Empirical data on the numbers of people crossing borders in Europe to obtain infertility treatment that they cannot obtain at home are lacking. A questionnaire covering the years 2000–2007 was completed by 16 of 18 Belgian centres for reproductive medicine. The total number of foreign patients was 1,456 in 2003 and has stabilised at about 2,100 annually since 2006, possibly due to legislative changes or better services in other countries. The majority of patients were French women seeking sperm donation. The next highest group were patients seeking ICSI with ejaculated sperm. The institutional policy of whether to accept lesbian couples and location of the centre were major factors in attracting patients. The countries from which most patients came were France (38%), Netherlands (29%), Italy (12%) and Germany (10%). The procedures sought included sperm donation, ICSI with ejaculated or donated sperm, ICSI with non-ejaculated sperm, IVF with own gametes or donated gametes, and pre-implantation genetic diagnosis. Belgian

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centres welcomed foreign patients and apart from the rule that they have to pay in advance, there were no special restrictions. Some of the patients had already had treatment in their own countries. Some had either reached an age where treatment was no longer free, or had had the permitted number of treatments. In some cases, patients sought IVF with more than one embryo to improve their chances of a successful pregnancy, when this was not permitted in their home country. There was a clear correlation between legal prohibitions on certain types of treatment in the patients’ home countries, the types of procedure sought, and the number of patients seeking those services.1 1. Pennings G, Autin E, Decleer W. Cross-border reproductive care in Belgium. Human Reproduction 2009;24(12):3108–18.

Non-commercial surrogacy in the Netherlands, 1997–2004 Surrogacy (a woman getting pregnant in order to give the baby to someone else) was prohibited in the Netherlands until 1994, when the law was changed from a general prohibition of surrogacy to the prohibition of commercial surrogacy. This paper reports the results from the first and only Dutch Centre for Non-Commercial IVF Surrogacy between 1997 and 2004. A prospective study was conducted using interviews and questionnaires with all intended parents and surrogate mothers and their partners (if present), to assess whether surrogacy offered a safe means of getting a baby, from a medical, psychological and legal perspective. More than 500 couples enquired about surrogacy by telephone or e-mail. More than 200 couples applied for surrogacy, of whom 105 couples came for a first consultation, 35 couples entered the IVF programme and 24 completed treatment, resulting in 16 children born to 13 women. Recommendations for non-commercial surrogacy are given, including abandoning the one-year waiting period before the intended parents adopt the child, currently dictated by law, which has created unnecessary psychological distress. Non-commercial IVF surrogacy is feasible, with good results in terms of pregnancy outcome and psychological outcome for all parents, and with no legal problems relating

to adoption procedures. The extensive screening of medical, psychological and legal aspects was a key element in ensuring safety and success.1 1. Dermout S, van de Wiel H, Heintz P, et al. Non-commercial surrogacy: an account of patient management in the first Dutch Centre for IVF Surrogacy, from 1997 to 2004. Human Reproduction 2010;25(2):443–49.

Abstinence in the sexuality education of low-income black girls, USA This paper describes a sexuality education programme for low-income black girls in a southern city in the United States that promoted sexual abstinence among the girls because they were perceived to be at risk sexually of pregnancy and abandonment. The teachers knew other women who were single mothers on low incomes, and they were trying to protect the girls from the same fate. They assumed the girls were sexually active, and they viewed sexual desire as a normal part of adolescence. But they felt the girls lacked the resources and social support to avoid pregnancy and to prevent it from limiting their life chances. The teachers recognised that being out of control of one’s surroundings is uncomfortable and indicative of low status. Teaching them that controlling their bodies by refusing sex was meant to give them pride in themselves, and a sense of control. However, the girls themselves had little control over the consequences of sex and an abstinence curriculum was inadequate for addressing their circumstances. By not teaching them fully about desire and responses to it, and about contraception and their options, they were still left with limited control. The author points out, however, that a feminist analysis of sexuality education based on advice to abstain from sex must take account not just of gender issues, but also of race and class and the context of young people’s lives, in order to understand the basis of the education provided. Because young, black teenage girls in the USA are seen as “bad” their teachers felt compelled to teach them to be “good” by inciting fear of sexuality. As a result, gender stereotypes were reinforced as a result of their efforts to challenge race and class stereotypes and inequalities.1 189

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1. Froyum CM. Making “good girls”: sexual agency in the sexuality education of low-income black girls. Culture, Health and Sexuality 2010;12(1):59–72.

Oral contraceptive discontinuation and its aftermath in 19 developing countries Oral contraceptives (OCs) are the second most widely used contraceptive method after intrauterine devices, and discontinuation of OCs is known to be high globally. This article focuses on OC discontinuation for reasons of dissatisfaction in 19 low- and middle-income countries, and whether women successfully switched to alternative methods. The probability of OC discontinuation was studied in relation to women's education and their motivation for using OCs. Data were taken from Demographic and Health Surveys conducted between 1999 and 2005 in eight Latin American, four Asian, four North African/Near Eastern and three sub-Saharan African countries. On average, 28% of women stopped OC use within 12 months for reasons implying dissatisfaction (ranging from 15% in Indonesia to over 40% in Bolivia and Peru), but only 35% of these women switched to another modern, effective method within three months (national estimates ranged from 17% to 57%). 16% switched to a less effective “traditional” method and 44%, who did not use another method, were at risk of pregnancy or had already become pregnant. Women’s education was weakly correlated with discontinuation but was a very strong predictor of early switching to another modern method. The motivation to prevent pregnancy (i.e. wanting no more children compared to wanting to delay the next pregnancy) clearly influenced willingness to persist with OC use and propensity to switch to another effective method. Discontinuation was lower and switching to another effective method higher in countries judged to have strong family planning programmes. Both discontinuation of use and inadequate switching to alternative methods are important problems in the family planning services of many developing countries, but neglected.1 1. Ali M, Cleland J. Oral contraceptive discontinuation and its aftermath in 19 developing countries. Contraception 2010;81:22–29.


Costs of treating complications of unsafe abortion in low- and middle-income countries Annually, an estimated 5.2 million women seek treatment for the complications of unsafe abortion and there has been recent interest in estimating the regional and global costs of unsafe abortion to inform policy and advocacy. This systematic review assesses the quality of costing studies of post-abortion care from low- and middle-income countries and describes the unit costs in various settings. 21 studies were analysed. There have been very few costing studies in Asia, Europe and the Middle East. Data indicate that the cost (in 2007 international dollars) of post-abortion care in Africa and Latin America is $392 and $430, respectively, per woman treated. Differences in the level of costs were associated with region, procedure, facility level, case severity, and whether the study reporting the data was an operations research study. The mean estimated cost of manual vacuum aspiration was $225 lower than that of dilatation and curettage (D&C), which supports the transition to vacuum aspiration, as recommended by the World Health Organization. Methods varied between studies, and efforts should be made in future research to improve consistency. Additional data are needed from Asia and Eastern Europe, as well as the costs of medical methods of uterine evacuation.1 One recent study using two different methods and results from 20 empirical studies estimated that the health system costs of treatment for the complications of unsafe abortion, euphemistically called post-abortion care, in African and Latin America combined range from $159 million to $333 million per year, putting a substantial financial burden on health systems.2 1. Shearer JC, Walker DG, Vlassoff M. Costs of post-abortion care in low- and middle-income countries. International Journal of Gynecology and Obstetrics 2010;108:165–69. 2. Vlassoff M, Walker D, Shearer J, et al. Estimates of health care system costs of unsafe abortion in Africa and Latin America. International Perspectives on Sexual and Reproductive Health 2009;35(3):114–21.

Abortion trends in France, 1990–2005 Abortion was legalised in France in 1975 and in 2001 the law was amended to facilitate access

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for all women. Using data from abortion notifications, this study analyses the trend in gestational age at termination between 1990 and 2005 according to women’s socio-demographic circumstances in order to examine the effect of the 2001 amendments on ease of access to abortion and trends in difficulties experienced by young women, foreign women and women having repeat abortions. An increase in gestational age at abortion between 1997 and 2002 shows that the extension of legal abortion from 12 to 14 weeks of pregnancy in 2001 became a practical reality. All categories of women were equally affected by this extension. The increase in abortion rates among young women continued in the 2000s and, as in the 1990s, is attributed to an increased number of abortions at young ages, owing to the postponement of family formation to older ages. Foreign women showed a greater propensity to have abortions (although this remained stable over the period), did not experience more difficulty accessing abortion, and had more repeat abortions. The proportion of repeat abortions increased between 1990 and 2002, possibly because abortion risks are now so low and women are not made to feel guilty for having abortions. Women now have the same risk of abortion, whatever their abortion history.1

and prevalence during pregnancy and/or in the year preceding pregnancy was 3.4%. Routine screening by a family physician or gynaecologist was acceptable. A Knowledge Attitude Practice (KAP) survey showed that gynaecologists largely underestimated the extent of intimate partner violence, with only 6.8% of respondents having received any relevant training. Gynaecologists did not in fact consider pregnancy as a window of opportunity for routine screening. Barriers included lack of self-efficacy to deal with violence, lack of familiarity with referral procedures, lack of time and fear of offending patients. It was concluded that physician training is essential. The 2008–2009 National Action Plan included evaluation of the Ghent University Hospital protocol − a treatment guideline and training tool for health workers − as well as plans to update and share it with other hospitals, along with training at those hospitals. Other activities in the Plan include the development of formal referral systems and multidisciplinary collaboration.1 1. Roelens K, Verstraelen H, Temmerman M. Intimate partner violence and role of health care workers: research to strengthen health systems. Entre Nous: European Magazine for Sexual and Reproductive Health 2009;68:20–21.

1. Rossier C, Toulemon L, Prioux F. Abortion trends in France, 1990–2005. Population 2009;64(3):443–76.

Intimate partner violence: research to strengthen health systems Intimate partner violence is a hidden epidemic with lifetime prevalence estimates of harm to women ranging from 10–69%, while partner abuse during pregnancy is thought to occur in 3–8% of pregnancies. Intimate partner violence has been a crime in Belgium since 1997, and in 2000 a National Action Plan was launched. A consensus was developed on the family physician’s role in detecting and dealing with intimate partner violence, but no recommendations regarding pregnant women were included. Most pregnant women in Belgium see an obstetriciangynaecologist for routine antenatal care and delivery. In a cross-sectional study of women attending antenatal care, the lifetime prevalence of intimate partner violence was 10.1% 191