- Email: [email protected]
Use of family planning services in Darfur, Sudan
BRIEF COMMUNICATIONS
with exocytosis of chronic inflammatory cells into the epithelium. Varying degrees of hyperkeratosis and parakeratosis were present in 14 of the 19 specimens. Additional findings included a noncaseating granuloma (1 case with co-existing lichen sclerosus), foreign body giant cell inflammation (2 cases with co-existing vulvar vestibulitis), and acute inflammation (2 cases: one with each lichen simplex and vulvar vestibulitis). Four of the 19 cases had a specific pathologic abnormality. Three confirmed a clinical diagnosis of lichen sclerosis, and one revealed changes consistent with a traumatic neuroma and scar tissue in a multiparous woman. Fibrosis was initially reported as a significant finding in the majority of specimens. However, a similar mix of fibrous tissue and smooth muscle bundles was noted on review of specimens of the vulva that did not have recurrent fissures. Oral granuloma fissuratum was initially described by Sutton in 1932 [4], and later reported occurring on the nose and ears [1]. It was subsequently noted that the name “granuloma fissuratum” was a misnomer, as the major histologic features included epidermal hyperplasia with fibrosis and chronic inflammation; with occasional notation of hyperkeratosis and parakeratosis [1]. In addition, granuloma fissuratum as described from sites other than the vulva is characterized by epidermal depressions with intact skin. On histologic review of the vulvar cases of recurrent mechanical fissure, what was initially thought to represent fibrosis was actually a constant histologic finding when compared with posterior fourchette specimens without the clinical diagnosis of recurrent mechanical
247
fissure. The initial reports of fibrosis reflect minimal exposure of pathologists to the microscopic anatomy of the submucosa of the posterior fourchette. Consequently, chronic inflammation, hyperkeratosis, and parakeratosis appear to be the only common, although nonspecific, histopathologic findings for granuloma fissuratum occurring elsewhere and recurrent mechanical fissure of the fourchette. Furthermore, despite the presence of a fissure, these findings are not likely to be representative of “granuloma fissuratum” occurring elsewhere and should therefore be referred to by description rather than the misnomer “granuloma fissuratum”. In summary, the development of vulvar fissures, while common with some vulvar dermatoses, may also occur as a primary finding with nonspecific histopathologic change. Acknowledgment The study was funded in part by the NICHD HD045769 as part of a K23 Career Development Award (CMK). References [1] Kennedy CM, Dewdney S, Galask RP. Vulvar granuloma fissuratum: a description of fissuring of the posterior fourchette and the repair. Obstet Gynecol 2005;105 (5 Pt 1):1018–23. [2] Edwards L. Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111–6. [3] Wong CS, Andrew S, Yell J. Isolated vulvar splitting–is this normal or pathological? J Obstet Gynaecol 2004;24(8):899–902. [4] Sutton Jr RL. A fissured, granulomatous lesion of the upper labio-alveolar fold. Arch Derm 1932;26:425–7.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.017
Use of family planning services in Darfur, Sudan Abder Haggaz a,⁎, Samah Ahmed b, Ishag Adam b a b
Alfasher University, Darfur, Sudan Faculty of Medicine, University of Khartoum, Sudan
a r t i c l e
i n f o
Article history: Received 2 October 2008 Received in revised form 22 October 2008 Accepted 24 October 2008 Keywords: Contraception Education Family planning services Sudan
High fertility rates and inadequate spacing between births can lead to high maternal and infant mortality. An estimated 600 000 maternal deaths occur worldwide each year, and the vast majority take place in low-income countries. The World Health Organization estimates that ⁎ Corresponding author. PO. Box 65, Department of Obstetrics and Gynecology, Faculty of Medicine University of Elfasher, Sudan. Tel.: +249911259199; fax: +249731830504. E-mail address: [email protected] (A. Haggaz).
13% of these deaths are due to unsafe abortions. Worldwide, where approximately 50 million women resort to induced abortion, this frequently results in high rates of maternal morbidity and mortality [1,2]. Family planning and adequate spacing between births are important methods to help avoid these deaths. Little published data are available regarding the use of family planning services in Sudan—the largest country in Africa, with 40 million inhabitants—although high maternal mortality and inadequate utilization of prenatal care in Darfur have been reported previously [3,4]. In Alfasher, the area considered in the present study, the Sudanese Family Planning Association has an office that provides services such as contraceptive pills and intrauterine contraceptive devices free of charge. A community-based cross-sectional household survey was conducted in Alfashar, in April and June 2008, to investigate the use of and factors associated with family planning services. Pretested structured questionnaires in the local Arabic language were administered to parous women of reproductive age (12–49 years) by a trained medical officer to gather data on family planning experiences and age, parity, and education. Informed consent was obtained from each respondent prior to the interview, which was conducted in private. Utilization of family planning services was defined as current or prior use of 1 or more family planning techniques (contraceptive pills, intrauterine
248
BRIEF COMMUNICATIONS
Table 1 Factors associated with use of family planning in Darfur, Sudan Variable
OR
95% CI
P value
Age, y Parity Women's education ≥ secondary level
1.0 0.9 6.4
0.9–1.0 0.7–1.0 3.6–11.2
0.9 0.1 b0.001
Abbreviations: OR, odds ratio; CI, confidence interval.
devices, injections, male condoms, female condoms, and female sterilization). Use of traditional techniques such as breastfeeding (lactational amenorrhea) and the rhythm method was also queried. Statistical analyses were conducted using SPSS (SPSS, Chicago, IL, USA). The proportion of women who used family planning was calculated, and logistic regressions models were generated using family planning as the dependent factor, and age, parity, and education levels of the women as independent variables. Confidence intervals of 95% were calculated and P b 0.05 was considered significant. The mean age of the 342 women enrolled in the study was 29.5 ± 6.3 years, and the mean parity was 3.8 ± 2.4. Of the participants, 34.2% had previously used or were currently using 1 or more of the family
planning methods. Contraceptive pills were used most frequently (74.4%), followed by injections (8.5%) and intrauterine devices (6.0%). Safe period/breastfeeding (lactational amenorrhea) was used by 8.5% of the women, 1.6% had undergone tubal ligation, and male condoms were used by 0.9%. Educational levels greater than or equal to secondary level were the most significant predictors of use of family planning services, while age and parity did not significantly affect use (Table 1). The most common reasons given by the respondents for not using these services were the desire for more children and fear of possible side effects. It is clear that educational programs to encourage uptake and better access to services are needed. References [1] World Health Organization. The World Health Report 2002. Statistical annex. Geneva: WHO; 2002. [2] WHO/UNFPA/UNICEF. Programming for Adolescent Health and Development. Report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. World Health Organization Technical Report Series, vol. 886. Geneva: WHO; 1999. [3] Haggaz AA, Radi EA, Adam I. High maternal mortality in Darfur, Sudan. Int J Gynecol Obstet 2007;98(3):252–3. [4] Haggaz A, Ahmed S, Adam I. Use of prenatal care services in Darfur, Sudan. Int J Gynecol Obstet 2008;103(3):252–3.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.022
with exocytosis of chronic inflammatory cells into the epithelium. Varying degrees of hyperkeratosis and parakeratosis were present in 14 of the 19 specimens. Additional findings included a noncaseating granuloma (1 case with co-existing lichen sclerosus), foreign body giant cell inflammation (2 cases with co-existing vulvar vestibulitis), and acute inflammation (2 cases: one with each lichen simplex and vulvar vestibulitis). Four of the 19 cases had a specific pathologic abnormality. Three confirmed a clinical diagnosis of lichen sclerosis, and one revealed changes consistent with a traumatic neuroma and scar tissue in a multiparous woman. Fibrosis was initially reported as a significant finding in the majority of specimens. However, a similar mix of fibrous tissue and smooth muscle bundles was noted on review of specimens of the vulva that did not have recurrent fissures. Oral granuloma fissuratum was initially described by Sutton in 1932 [4], and later reported occurring on the nose and ears [1]. It was subsequently noted that the name “granuloma fissuratum” was a misnomer, as the major histologic features included epidermal hyperplasia with fibrosis and chronic inflammation; with occasional notation of hyperkeratosis and parakeratosis [1]. In addition, granuloma fissuratum as described from sites other than the vulva is characterized by epidermal depressions with intact skin. On histologic review of the vulvar cases of recurrent mechanical fissure, what was initially thought to represent fibrosis was actually a constant histologic finding when compared with posterior fourchette specimens without the clinical diagnosis of recurrent mechanical
247
fissure. The initial reports of fibrosis reflect minimal exposure of pathologists to the microscopic anatomy of the submucosa of the posterior fourchette. Consequently, chronic inflammation, hyperkeratosis, and parakeratosis appear to be the only common, although nonspecific, histopathologic findings for granuloma fissuratum occurring elsewhere and recurrent mechanical fissure of the fourchette. Furthermore, despite the presence of a fissure, these findings are not likely to be representative of “granuloma fissuratum” occurring elsewhere and should therefore be referred to by description rather than the misnomer “granuloma fissuratum”. In summary, the development of vulvar fissures, while common with some vulvar dermatoses, may also occur as a primary finding with nonspecific histopathologic change. Acknowledgment The study was funded in part by the NICHD HD045769 as part of a K23 Career Development Award (CMK). References [1] Kennedy CM, Dewdney S, Galask RP. Vulvar granuloma fissuratum: a description of fissuring of the posterior fourchette and the repair. Obstet Gynecol 2005;105 (5 Pt 1):1018–23. [2] Edwards L. Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111–6. [3] Wong CS, Andrew S, Yell J. Isolated vulvar splitting–is this normal or pathological? J Obstet Gynaecol 2004;24(8):899–902. [4] Sutton Jr RL. A fissured, granulomatous lesion of the upper labio-alveolar fold. Arch Derm 1932;26:425–7.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.017
Use of family planning services in Darfur, Sudan Abder Haggaz a,⁎, Samah Ahmed b, Ishag Adam b a b
Alfasher University, Darfur, Sudan Faculty of Medicine, University of Khartoum, Sudan
a r t i c l e
i n f o
Article history: Received 2 October 2008 Received in revised form 22 October 2008 Accepted 24 October 2008 Keywords: Contraception Education Family planning services Sudan
High fertility rates and inadequate spacing between births can lead to high maternal and infant mortality. An estimated 600 000 maternal deaths occur worldwide each year, and the vast majority take place in low-income countries. The World Health Organization estimates that ⁎ Corresponding author. PO. Box 65, Department of Obstetrics and Gynecology, Faculty of Medicine University of Elfasher, Sudan. Tel.: +249911259199; fax: +249731830504. E-mail address: [email protected] (A. Haggaz).
13% of these deaths are due to unsafe abortions. Worldwide, where approximately 50 million women resort to induced abortion, this frequently results in high rates of maternal morbidity and mortality [1,2]. Family planning and adequate spacing between births are important methods to help avoid these deaths. Little published data are available regarding the use of family planning services in Sudan—the largest country in Africa, with 40 million inhabitants—although high maternal mortality and inadequate utilization of prenatal care in Darfur have been reported previously [3,4]. In Alfasher, the area considered in the present study, the Sudanese Family Planning Association has an office that provides services such as contraceptive pills and intrauterine contraceptive devices free of charge. A community-based cross-sectional household survey was conducted in Alfashar, in April and June 2008, to investigate the use of and factors associated with family planning services. Pretested structured questionnaires in the local Arabic language were administered to parous women of reproductive age (12–49 years) by a trained medical officer to gather data on family planning experiences and age, parity, and education. Informed consent was obtained from each respondent prior to the interview, which was conducted in private. Utilization of family planning services was defined as current or prior use of 1 or more family planning techniques (contraceptive pills, intrauterine
248
BRIEF COMMUNICATIONS
Table 1 Factors associated with use of family planning in Darfur, Sudan Variable
OR
95% CI
P value
Age, y Parity Women's education ≥ secondary level
1.0 0.9 6.4
0.9–1.0 0.7–1.0 3.6–11.2
0.9 0.1 b0.001
Abbreviations: OR, odds ratio; CI, confidence interval.
devices, injections, male condoms, female condoms, and female sterilization). Use of traditional techniques such as breastfeeding (lactational amenorrhea) and the rhythm method was also queried. Statistical analyses were conducted using SPSS (SPSS, Chicago, IL, USA). The proportion of women who used family planning was calculated, and logistic regressions models were generated using family planning as the dependent factor, and age, parity, and education levels of the women as independent variables. Confidence intervals of 95% were calculated and P b 0.05 was considered significant. The mean age of the 342 women enrolled in the study was 29.5 ± 6.3 years, and the mean parity was 3.8 ± 2.4. Of the participants, 34.2% had previously used or were currently using 1 or more of the family
planning methods. Contraceptive pills were used most frequently (74.4%), followed by injections (8.5%) and intrauterine devices (6.0%). Safe period/breastfeeding (lactational amenorrhea) was used by 8.5% of the women, 1.6% had undergone tubal ligation, and male condoms were used by 0.9%. Educational levels greater than or equal to secondary level were the most significant predictors of use of family planning services, while age and parity did not significantly affect use (Table 1). The most common reasons given by the respondents for not using these services were the desire for more children and fear of possible side effects. It is clear that educational programs to encourage uptake and better access to services are needed. References [1] World Health Organization. The World Health Report 2002. Statistical annex. Geneva: WHO; 2002. [2] WHO/UNFPA/UNICEF. Programming for Adolescent Health and Development. Report of a WHO/UNFPA/UNICEF study group on programming for adolescent health. World Health Organization Technical Report Series, vol. 886. Geneva: WHO; 1999. [3] Haggaz AA, Radi EA, Adam I. High maternal mortality in Darfur, Sudan. Int J Gynecol Obstet 2007;98(3):252–3. [4] Haggaz A, Ahmed S, Adam I. Use of prenatal care services in Darfur, Sudan. Int J Gynecol Obstet 2008;103(3):252–3.
0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.10.022