Ethical considerations in teaching intimate examination procedures to medical students
The balance between the educational needs of medical students and ethical obligations towards patients has always been difficult to achieve, but it is a particular problem where intimate medical examinations are involved. To begin with, there is no consensus as to what constitutes an intimate examination. An article by Coldicott, Pope and Roberts1 on the ethics of teaching intimate examinations sparked off considerable correspondence, which went much wider than the original debate. A group of 386 medical students in the UK from all years had performed both rectal and vaginal examinations. The number of students performing such examinations and the number of examinations done increased substantially by the fourth year, as students are required to perform a minimum of ten vaginal examinations as part of their training in reproductive medicine. Students in their second and third years frequently did not know whether consent had been obtained from the patient they were examining. Many were uncomfortable with this situation but felt unable to challenge the consultant. As there are clear guidelines on both the teaching of vaginal examinations and the need for patient consent, this highlights the difference between policy and practice. It is difficult to know if such poor practice is widespread or how it can be rectified. One option is to increase the use of alternative training methods, such as using mannequins2 or non-patient volunteers.3,4 Further training in how students might obtain consent whilst respecting a patient's right to refuse is also necessary.2
An extension of this debate argues that all examinations are intimate and that it is not necessary to distinguish vaginal, breast or rectal examinations from other types of examination–they should all be treated as needing the same level of ethical consideration.5 However, there is little doubt that some women, particularly younger women, find pelvic examinations distressing.6 The evidence for the usefulness of such examinations is thought to be overstated by some in the field, who think they should be stopped altogether or should only be taught to those post-graduate students who will need those particular skills.7
There is no easy answer to this conflict between educational needs, enabling students to learn skills they may or will need as they become practitioners, and ethical requirements that such procedures should have no deleterious effect. Nevertheless, current poor practice must be eliminated and practice regularly evaluated.7
1. Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations–teaching tomorrow's doctors. BMJ 2003;326:97–99.
2. MacDougall J. Commentary: teaching pelvic examination–putting the patient first. BMJ 2003;326:100–01.
3. Hendrickx K, de Winter B, Wyndale J-J. Please don't touch me there: the ethics of intimate examinations [Letter]. BMJ 2003;326:1327.
4. Nestel D, Kneebone R. Please don't touch me there: the ethics of intimate examinations [Letter. BMJ 2003;326:1327-a.
5. Kaushik NC. Please don't touch me there: the ethics of intimate examinations [Letter]. BMJ 2003;326:1326-b.
6. Fiddes P, Scott A, Fletcher J, et al. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception 2003:67(4):313–17.
7. Tonks A. Please don't touch me there: the ethics of intimate examinations; summary of rapid responses [Letter]. BMJ 2003;326:1327-b.
Using peer educators to deliver sex education
Peer-led health education is commonly believed to have distinctive features, such as increased empathy with and similarity to students, which lead to increased student satisfaction and learning compared to teacher-led education. The RIPPLE study in the UK of the effectiveness of sex and relationship education, using peer educators aged 17–18 for students aged 13–14, supports this finding. Student evaluations show that a greater proportion of students found the sessions enjoyable, engaging and useful when taught by peer educators rather than by teachers. The differences seem to lie in the peer educators' choice of lesson content and teaching methods, as well as the sexual attitudes and values they espoused. In peer-led lessons, students saw and touched contraceptives, worked in small groups, asked more questions, took away more leaflets and learnt more new things than in teacher-led sessions. However, the teachers were less likely to get embarrassed and their sessions were better controlled. Contextual factors such as a student's prior relationship with the educator played a considerable role in positive vs. negative evaluations of sessions. It is particularly interesting that students were more confident in the knowledge imparted by peers than by teachers. In this respect, it may be significant that the peer educators had had specific training in active learning techniques by health promotion practitioners whereas the teachers had not.
Isle of Sheppey, Great Britain, 1997
Much teacher-led sex education is patchy and often seen as peripheral to the core curriculum. The positive feedback from students reported here suggests that a discrete, peer-led programme implemented by motivated and enthusiastic educators may be a way to improve sexuality education. Such a programme would have to consider the differing needs of boys and girls, and the various age groups.1
1. Forrest S, Strange V, Oakley A. A comparison of students' evaluations of a peer-delivered sex education programme and teacher-led provision. Sex Education 2002;2(3);195–214.
Sex and Drugs touchscreen game for school students
A Sheffield-based marketing and communications company in the UK has created an interactive computer touchscreen game, called Selector, which uses animation and different genres of music to navigate students through information on sexual health, drugs, relationships and self-esteem. The work was commissioned by Sheffield Teenage Pregnancy Strategy, the Centre for HIV and Sexual Health, Sheffield City Council and Sheffield Drug Action Team, and is being piloted at 18 sites across the city in places where young people learn, live and socialise. The students like it because it looks like a computer game, and they like the language used to convey the messages. Even pupils who are ordinarily difficult to engage are using it in their free time-in the first three days after the console was delivered at one school it was used by over 100 pupils during their lunch hour. The game allows students to absorb highly accurate information using contemporary language and images to get key messages across and is being used in areas where young people have limited access to interactive resources.1
1. Sex and Drugs touchscreen game gets messages across. Diva Creative Ltd. News release, 30 June 2003. At: 〈http://www.divacreative.com/whatsnew.html〉.
Health needs of lesbian women: UK data
Most health needs of lesbian women are not significantly different from those of other women. In common with all women, around one in five lesbians carries human papillomavirus and needs a regular cervical smear. Although lesbian women are less likely to contract most STIs, 10% of women with exclusively women partners have a history of a sexually transmitted infection. Female-to-female transmission of HIV has rarely been reported, though injection drug use is a source of risk. As a group lesbian women show an increased risk of suicide, deliberate self-harm, and depression and anxiety disorders. Although it is difficult to establish causality, the isolation, social stigma and statutory prejudice against homosexuality must be a component of these problems. Not having used oral contraception or been pregnant may mean that lesbian women have an increased risk of breast, ovarian, endometrial, lung and colon cancer and a theoretically increased risk of cardiovascular disease.However, some of these risks are related to lifestyle factors such as smoking, alcohol use and obesity, not sexual orientation. They do highlight the need for health professionals to take a non-judgemental approach, and enable lesbian women to access and receive appropriate health care fully.1
1. Hughes C, Evans A. Health needs of women who have sex with women. BMJ 2003;327:939–40.
Sexuality and intersex conditions
When babies are born with ambiguous genitalia, the medical profession moves along a path towards sex-reassignment using various degrees of genital surgery and hormonal treatment. Which sex a baby is assigned depends on the underlying condition and local policy. Thus, one hospital in the Netherlands changed in 1995 to assigning male sex to most babies, whereas previously they were more likely to assign female sex.1
The quality of life of individuals with this history has been occasionally investigated, especially with reference to psychological and sexual development. A recent study of 28 sexually active women with intersex origins showed that they all had sexual difficulties, including lack of sensuality and an inability to achieve orgasm. These difficulties were worse in 18 of the women who had undergone clitoral surgery, suggesting that surgery may compromise sexual function.2 However, there are other reasons for inadequate sexual functioning among those with intersex conditions. Gender behaviour which is usually perceived to be masculine may exclude those assigned female sex from the social world of girls and women. Problems with vaginal penetration can make sex uncomfortable. Self-consciousness about genitalia may make assigned women avoid sexual contact. The cohort in the study suffered from a range of underlying conditions, which required different approaches to treatment.3 Formulating criteria for genital surgery and appropriate sexual counselling is difficult. The joint working group on congenital adrenal hyperplasia has a policy on genital surgery in affected girls but criteria for the range of procedures between reducing the size of a large clitoris and complete repair with vaginoplasty and clitoral and labial surgery are by no means clear.1
1. Slijper FME. Clitoral surgery and sexual outcome in intersex conditions. Lancet 2003;361:1236–37.
2. Minto CL, Woodhouse CRJ, Ransley PG, et al. The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study. Lancet. 2003;361:1252–57.
3. Tovar JA. Clitoral surgery and sexual outcome in intersex individuals. Lancet 2003;362:247–48.
Sensory disabilities and sexuality
The understanding of one's own sexuality is a continuing process arrived at using a range of direct personal experiences, written information, and communication with and observation of others. Those with sensory disabilities–varying degrees of blindness or deafness–can have problems coming to terms with their sexuality. A blind woman would not have observed the development of breasts in her peers; a deaf woman may not have had menstruation clearly explained to her. Additionally, sexual expression is strongly linked to self-image, and self-image in those with sensory disabilities may be poor as a result of negative reactions from family, friends and the community at large. Frequently there are expectations that disabled women are asexual, and that relationships and marriage are to be discouraged.
Addressing these problems requires an interdisciplinary and integrated approach. It should tackle areas such as the formation of relationships, the promotion of self-esteem and an acceptance of sexuality. In particular sex education for people with sensory impairment requires highly visual materials for the deaf and tactile and audio materials for the blind. Other important elements are support for parents, education of the public that disabled people have normal sexual desires and needs, and availability of specially-trained counselling services. Implementation of such strategies should lead to healthy sexual development in those with sensory disabilities.1
1. Limaye S. Sexuality and women with sensory disabilities. In: Hans A, Patri A (editors). Women, Disability and Identity. Delhi: Sage Publications, 2003.
New rapid test for chlamydia
Chlamydia is one of the most common STIs, with almost 100 million reported new cases a year worldwide. There are no symptoms in over half the cases of infection but chlamydia can cause tubal blockage leading to infertility and ectopic pregnancy. The disease is easily treated with a single dose of the right antibiotic, but what has been missing is an inexpensive, on-the-spot test that avoids the need for repeat visits to a clinic. “Firstburst” is a cheap and quick dipstick test that uses either urine or vaginal swabs for analysis. It is due for distribution across Africa and Asia by Diagnostics for the Real World in the near future.1
1. Wellcome Trust. Rapid test for hidden disease [Press release]. 17 December 2003.
Helping auxiliary nurse-midwives to live locally in Rajasthan
One of the keys to reducing maternal mortality is the provision of a skilled attendant at birth. In India, auxiliary nurse-midwives (ANMs) can play this role, particularly in rural communities, but it is less useful if they cannot easily attend deliveries at unsocial hours or have insufficient time to visit all the households needing their services. One way to maximise the use of their time and to help them establish good relations with the community where they work is for them to live locally. Yet nearly half of all ANMs across India (43%) and almost two-thirds of the 231 ANMs taking part in this study (62%) commuted to work. Key factors in choosing to commute were poor quality of local accommodation, non-availability of essential items such as electricity, milk or vegetables, and lack of amenities such as schools for their children. Two-thirds of the ANMs questioned thought their sub-centres were unsafe for living in, particularly when they were located outside the main village. Many reported incidents of harassment and intimidation, and there was little evidence of support from supervisors when problems were encountered. If communities want ANMs to live locally, they and the government need to take appropriate action. This includes giving panchayats (village leaders) responsibility for the personal safety and living conditions of ANMs; forming complaints committees at district level for women health workers; developing policy guidelines for ANMs that would make for more logical recruitment, such as recruiting rural women to work in rural areas; locating accommodation for ANMs based on their personal and family needs; and encouraging NGOs to support ANMs.1
1. Mohan P, Iyengar SD, Mohan SB, et al. Why would an auxiliary nurse-midwife (ANM) of Rajasthan prefer to reside within her work area? Udaipur: Action Research & Training for Health, 2003.
Greater sensitivity of ultrasound in pregnancy poses new clinical decisions
Ultrasound screening of pregnant women has become so sensitive that it can detect minor anatomical variations in the fetus, and this is creating some difficult clinical decisions. These variations may indicate an increased likelihood of a chromosomal abnormality such as trisomy 21 (which causes Down's syndrome), but they may also be within the range of normality. To resolve any clinical uncertainty, further tests may be called for. This poses the dilemma of whether all such findings of an ultrasound examination should be reported to parents and whether more invasive tests should be used to resolve all cases of uncertain clinical diagnosis. These areas need more full investigation before policy on disclosure and further screening is implemented.1
1. Getz L, Kirkengen AL. Ultrasound screening in pregnancy; advancing technology, soft markers for foetal chromosomal aberrations, and unacknowledged ethical dilemmas. Social Science and Medicine 2003;56(10):2045–57.
Donor eggs and cryopreserved ovarian tissue for infertile women
Despite considerable advances in assisted reproductive techniques, the options for infertile women and those facing loss of fertility are still limited. One possibility is the use of donor eggs, but the cryopreservation of donor eggs, unlike with sperm and embryos, is still an experimental technique. There have been relatively few children born worldwide from frozen eggs and few studies to date have compared the various possible techniques. Thus, concerns about safety, damage from freezing and uncertain pregnancy success rates remain to be resolved.1 However, successful pregnancies have been reported, particularly by the use of intracytoplasmic sperm injection (ICSI),2,3 possibly reaching the levels of success expected from fresh eggs and frozen embryos. The use of frozen eggs rather than a frozen embryo has a number of advantages for the infertile woman, such as the avoidance of ethical issues related to the later use or disposal of surplus embryos.4
Cryopreserved ovarian tissue offers another alternative for women facing the loss of fertility. Ovarian tissue is easily preserved and easily transplanted to a variety of tissue sites where it can grow and give rise to mature oocytes which can then be harvested for in vitro fertilisation. This is a useful technique for restoring fertility to an individual using her own tissue, but such tissue would be rejected if transplanted to another individual. The possibility of overcoming such rejection to allow for transplants between patients is under investigation.5
1. Gosden RG. Low temperature storage of follicular and ovulated oocytes. In: Trounson AO, Gosden RG (editors). Biology and Pathology of the Oocyte. Cambridge: Cambridge University Press, 2003.
2. Porcu E, Fabbri R, Damiano G, et al. Clinical experience and applications of oocyte cryopreservation. Molecular and Cellular Endocrinology 2000;169(1/2):33–37.
3. Quintans CJ, Donaldson MJ, Bertolino MV, et al. Birth of two babies using oocytes that were cryopreserved in a choline-based freezing medium. Human Reproduction 2002;17(12):3149–52.
4. Women lose embryo battle. BBC News. 1 October 2003. At: 〈http://news.bbc.co.uk/1/hi/health/3151762.stm〉.
5. Shaw JM, Cox S-L. Fecundity of transplanted ovaries. In: Trounson AO, Gosden RG (editors). Biology and Pathology of the Oocyte. Cambridge: Cambridge University Press, 2003.
Donating semen in Sweden
The laws regarding anonymity for semen donors vary from country to country. In Sweden, following a change in policy several years ago, donors know that they will be identified on request to any offspring who ask for the information when they reach maturity. A recent study of 30 Swedish semen donors showed that their sole or main motivation for donating semen was to help infertile couples, but support from their own partner was a factor in the decision too. More than half felt they should receive payment for the donation and reimbursement of expenses was also considered important. This study demonstrates that semen donors can be recruited in a system which requires them to be prepared to be identified to future offspring.1 This will become important in the UK, where the law is being changed so that donor anonymity will no longer be guaranteed, whether for donors of sperm, eggs and embryos after April 2005.2 The Swedish experience suggests that fears of a drop in the number of donors in the UK in the light of the new legislation may be groundless.
1. Lalos A, Daniels K, Gottlieb C, et al. Recruitment and motivation of semen providers in Sweden. Human Reproduction 2003;18(1):212–16.
2. Boseley S. Donor children will have right to know. Guardian (UK). 22 January 2004.
Contraceptive implants 20 years on
In 1983 the first contraceptive implant, Norplant, developed as a more convenient and long-term way to administer contraceptive hormones, was approved for use. Norplant and two other, more recently licensed brands, Jadelle and Implanon, are now used by 11 million women worldwide. The 20-year experience of Norplant confirms its high level of effectiveness, a pregnancy rate of 1.5% over a five-year follow-up period. Appropriately used, implants have been shown to be cost-effective in the USA and UK by the third year of use. Studies of cost-effectiveness in developing countries have not been carried out. The biggest drawback to increased use of implants is the need for minor surgery to insert or remove them, which requires skilled providers, adequate counselling and follow-up, and that implant removal is available when requested. The newer implants have an advantage in that with fewer capsules or rods, they are easier and safer to insert and remove. It seems likely that most programmes will move to these as Norplant implants come to be replaced.1
With Norplant, menstrual bleeding symptoms are usually most severe in the first year of use, but as total blood loss is similar to that of normal menstruation, anaemia is rare. However, changes from a normal bleeding cycle are the main reason given by 10–30% of users for discontinuation and as yet there has been little progress in finding a method to treat irregular bleeding. A recent multicentre study looked at the problems encountered by 752 women who discontinued use of Norplant for menstrual bleeding reasons within three years of insertion and compared their experiences with those of 2,667 women who continued use of the implants. Women who discontinued use for other reasons were excluded from the analysis. Duration of bleeding of more than seven days was the most common reason for discontinuation. Other symptoms associated with discontinuation were excessive flow, dysmenorrhoea and inter-menstrual bleeding for more than seven days. There was a higher risk of discontinuation among Asian and Central American participants than among African women. As there is no medical treatment for this side effect of contraceptive implants, counselling before and during use on coping with bleeding is important.2
1. World Health Organization. Contraceptive implants come of age. Progress in Reproductive Health Research 2003;61:1–8.
2. Rivera R, Rountree W. Characteristics of menstrual problems associated with Norplant discontinuation: results of a multinational study. Contraception 2003;67:373–77.
Tamoxifen in the prevention of breast cancer
Treatment of early breast cancer with tamoxifen and chemotherapy is a clinically proven method of significantly reducing mortality in patients. Now, tamoxifen and similar substances such as raloxifene are being considered for prophylaxis against the development of breast cancer. Studies have shown that by treating women with tamoxifen for five years, there is an overall reduction of 38% in the development of breast cancer, a figure which rises to 48% when only oestrogen-receptor-positive breast cancers are considered. To put this into context, this means that the treatment of 14,192 women with tamoxifen for five years will prevent an estimated 132 breast cancers. However the number of women on treatment who might develop a thromboembolism would more than double and the number of strokes would increase by 50%. Considering both the health benefits and risks and the cost, mass preventative treatment does not seem a viable option, although there might be some value in treating high-risk women only. If this were the case then only 5% of white women in the USA would be candidates for the regimen and smaller numbers of women of other races who have a lower initial risk. It seems that for better control of breast cancer, better early detection systems and more tailored markers of risk may be needed rather than preventative treatment with tamoxifen.1
1. Bergh J. Breast cancer prevention: is the risk–benefit ratio in favour of tamoxifen? Lancet 2003;362:183–84.
Elective caesarean deliveries–benefits and risks
As women are living longer and having fewer children, and as childbirth becomes safer for women and their babies, quality-of-life issues related to childbirth become more important. At the same time, women are having an increasing say in obstetric decision-making, a right reinforced by both legal and ethical considerations. This has brought about highly controversial discussions about elective caesarean section as a delivery option in the absence of clear clinical indications. The International Federation of Obstetricians and Gynecologists considers that “performing caesarean deliveries for non-medical reasons is ethically unjustified”,1 while others believe that a physician should “accede to an informed patient's request for such a delivery”.2
Planned deliveries have the advantage of decreasing pressure on staff, which could improve quality of delivery care and reduce adverse effects that can arise from understaffing and fatigue. Data on the benefits of elective caesarean delivery are not always conclusive, however. There is a body of evidence suggesting that the risk of long-term urinary incontinence, occurring in up to 10% of vaginal deliveries, may be halved by caesarean delivery, particularly if it is performed before the onset of labour. Benefits to the infant are less clear. Compared to vaginal delivery, there may be a reduction in stillbirths after 39 weeks, in mother-to-child transmission of infections such as HIV, and in damage due to failed labour, but apart from HIV infection, some of these are rare events for which as many as 400 caesarean sections would need to be performed to reduce a single case.
Increased risk of maternal death has always been considered the greatest drawback to elective caesarean delivery, a risk (based mostly on older data) believed to be increased by several times. However, older data do not distinguish between elective and emergency caesareans, and procedures are improving all the time. In the UK, for example, there has been a gradually decreasing relative risk from eight-fold in 1990 to two-fold in 1999. One very recent study on elective caesarean vs. vaginal delivery actually showed a lower mortality–one death in 78,000 women in the UK.
However, there is evidence of a higher risk of maternal death in subsequent pregnancies, with an increased probability of uterine rupture, placental abnormalities and ectopic pregnancy. Post-operative complications including infections, haemorrhage and visceral injury, rehospitalisation after childbirth, and the effect of adhesion formation after caesarean delivery on subsequent abdominal surgery are other possible drawbacks to elective caesarean deliveries, which have not been fully evaluated. The risks to the infant of caesarean delivery seem minimal (as long as too early delivery is avoided), although pulmonary problems may occur when it is performed before 39 weeks. At 39 weeks, this risk falls to about four per 1000 births.2
However, a recent study has, for the first time, suggested an association between antepartum stillbirth and previous caesarean delivery. The number of stillbirths recorded in the study was small; in over 120,000 women, the absolute risk was 1.77 per 1000 for women with a previous caesarean section compared to 0.89 per 1000 for other women.3 This increased risk of a relatively rare event raises the question of how best to communicate such information to women and couples, how they will view the increased risk and the extent to which such data will enter the debate on elective caesarean section.4
Overall, although complications in the mother are more common after caesarean section, the rate of adverse events appears to be declining. In particular, maternal deaths may no longer be the main feature in the risk–benefit analysis of the procedure at least in settings where appropriate levels of health care are available. Breastfeeding and mother–infant relationships do not seem to be affected by the choice of elective caesarean. Although there is not enough evidence to support a recommendation of routine elective caesarean delivery, and recent evidence on subsequent risk of stillbirth makes it less attractive, these authors believe the shift in the risk–benefit balance means physicians may need to take seriously requests from women for this type of delivery, with appropriate counselling and a fair assessment of the options.2,4
1. Schenker JG, Cain JM. FIGO committee report: FIGO committee for the ethical aspects of human reproduction and women's health. International Journal of Gynecology and Obstetrics 1999;64:317–22.
2. Minkoff H, Chervenak FA. Elective primary cesarean delivery. NEJM 2003;358(10):946–50.
3. Smith GCS, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362:1779–84.
4. Lumley JM. Unexplained antepartum stillbirth in pregnancies after a caesarean delivery. Lancet 2003;362:1774–75.
Female sterilisation in Brazil
Over the last 30 years, Brazilian couples have relied almost exclusively on either the pill or female sterilisation for contraception. Sterilisations are usually performed after a caesarean section partly in order for the procedure to be covered by health insurance costs, but mainly because sterilisations at other times were mostly illegal. This has led to an excess of caesarean deliveries amongst women wanting to be sterilised. The 1997 law on family planning and sterilisation was introduced to equalise access to sterilisation between the public and private sectors and to reduce the numbers of caesarean deliveries by legalising sterilisation.
This study among 1,612 women asked them about their future childbearing intentions and contraceptive choices, interviewing them twice during pregnancy and once post-partum. Of the 515 women who consistently declared they wanted no more children and who met the legal age–parity requirements for sterilisation, post-partum sterilisation was the most common choice of contraception, mentioned by 38% of private sector patients and 45% of public sector patients at the first antenatal interview, dropping to 36% and 31% respectively at the second antenatal interview. The pill, later sterilisation, IUD and for private patients only, vasectomy, each accounted for about 10% of the remaining choices mentioned. Of the women who intended to be sterilised post-partum, the number who were actually sterilised was significantly greater in the private sector (69%) than in the public sector (33%). Nineteen out of 86 women in the public sector had made arrangements for a post-partum sterilisation but it fell through, and 27 had tried to obtain a sterilisation before becoming pregnant with their last child. Almost all the sterilisations were performed after a caesarean section. In the post-partum interview, some respondents who had previously expressed a desire to be sterilised had changed their minds (11% public patients; 16% private patients) but only four of those who had been sterilised expressed any regret.
This study shows a substantial demand for female sterilisation in general and for post-partum sterilisation in particular among both private and public sector patients. It is clear that it is easier to obtain the procedure in the private sector, particularly after caesarean delivery, and that demand, particularly among women attending public health facilities, is not being met. Post-partum sterilisation following vaginal delivery should be reconsidered to meet this demand.1
1. Potter JE, Perpétuo IHO, Berquó E, et al. Frustrated demand for postpartum female sterilisation in Brazil. Contraception 2003;67:385–90.
Simple techniques may replace hysterectomy for menorrhagia
The UK National Institute for Clinical Excellence (Nice) has declared safe two new alternatives to hysterectomy techniques–microwave endometrial ablation and balloon thermal endometrial ablation–which remove the lining of the uterus, but not the uterus itself. These minimally invasive techniques can be used instead of hysterectomy for many women who suffer from heavy menstrual periods. They are quick to perform and the recovery period is short, but there may be a small risk of perforation of the uterus and of bowel injury. Like hysterectomy, these techniques make a woman unable to have further children. These techniques and other changes in the treatment of menorrhagia should cause the number of hysterectomies performed to fall in the coming years.1
1. Boseley S. Three-minute hysterectomy declared safe. Guardian (UK). 28 August 2003. At: 〈http://search.guardian.co.uk〉.
Critical need for midwifery training in Botswana
The Botswana Obstetric Record (BOR) is a 21-page booklet which aims to provide valuable information for the early diagnosis of problems during pregnancy, labour, delivery and puerperium, as well as providing detailed statistics for maternal morbidity and mortality monitoring. It records critical information relating to a woman's child-bearing history, including pregnancy history and details of labour, delivery, postnatal care and family planning. To complete the BOR requires access to and understanding of equipment for testing blood pressure, laboratory facilities for testing urine samples, manuals and facilities for performing a caesarean section and a supply of relevant drugs for obstetric complications.
The burden of completing the BOR falls to the nurses in the primary health care system, and in particular to the non-midwife nurses who make up two-thirds of the nursing force. In rural areas, all nurses, regardless of training, are expected to do all aspects of maternal care, childcare, family planning, health education and the work of pharmacy technicians. Thus the non-midwife nurse is vital in the monitoring and identification of maternal danger signs, completing the BOR and assisting pregnant women, often in isolated situations.
A study of 309 nurses working in hospitals, clinics and health posts showed that a nurse's ability to complete the BOR was significantly related to having had midwifery training, level of basic nursing training, age group, level of income, job satisfaction, adequacy of peer reliance and self-reliance for information on new nursing practices. They were also working in an adequately equipped health facility and able to consult with peers. The single most important factor, however, was midwifery training for promoting safe motherhood.
This study suggests that it is better to upgrade all nurses to nurse-midwives than to upgrade enrolled nurses to the level of registered nurse without midwifery training. This is especially important for nurses working in remote facilities at the periphery of the health care system, as they are the nurses routinely involved in completing the BOR and supporting pregnant women. Making midwifery training compulsory would help to achieve the required capacity for effective maternal care and treatment of obstetric complications. Whilst two-thirds of the nurses in Botswana, including the majority of those in remote areas, remain without midwifery training, the plan for safe motherhood will be compromised. Non-midwife nurses will continue to be left in charge in situations that are beyond their competence, skills and experience.1
1. Fako TT, Forcheh N, Ncube E. Prospects of safe motherhood in Botswana: midwifery training and nurses' ability to complete the Botswana obstetric record. Social Science and Medicine 2004:58:1109–20.
Women's status in Bangladesh improved by doorstep family planning services
The 20-year programme of delivering family planning services to rural households in Bangladesh has significantly increased contraceptive use. In 1997, the doorstep delivery of services was discontinued and replaced with community clinic services. Doorstep delivery definitely improved family planning uptake, but its effect on women's autonomy and status in Bangladesh has long been controversial. Bangladesh is a strongly patriarchal society and women's status is lower than in some other Asian countries, to the detriment of both maternal and child health. There has been concern that family welfare assistants visiting women at home would reinforce female dependency, seclusion and purdah, preventing improvements in women's status that might otherwise have occurred. Alternative arguments have suggested that the doorstep service benefited women in a number of ways, with the assistants directly receiving wages and gaining mobility, prestige and authority from their work. These large numbers of empowered women could have a positive effect on other women and girls in the villages, increasing the acceptability of women working and also extending family planning services to less accessible groups. Evidence on either of these perspectives has rarely been quantified, but a recent analysis of the social impact of doorstep services shows that they are positively associated with women's status, and that status improves with an increasing number of visits. The gender benefits come mainly from the programme's impact on fertility regulation by fostering reproductive autonomy, rather than directly from the interaction involved in a household visit. The fall in the fertility rate in Bangladesh has recently slowed mainly because of a decrease in effective family planning. In 2003, the Ministry of Health and Family Welfare reinstated doorstep services. [1]
1. Ketende C, Gupta N, Bessinger R. The impact of household delivery of family planning services on women's status in Bangladesh. International Family Planning Perspectives 2003;29(3):138–45.
Accessing non-prescription emergency contraception in Europe
Emergency contraception (EC) is available on a non-prescription basis in over 25 countries worldwide either over-the-counter (OTC) or behind-the-counter (BTC), the latter requiring interaction with the distributing pharmacist. Focus group discussions involving 98 women in four European countries who had used EC at least once showed strong support for pharmacy access to EC, but there were mixed views on the counselling given by pharmacists. Some found it supportive, but for others it was embarrassing, with some pharmacists perceived as patronising, judgemental or poorly informed. All the participants relied heavily on the package inserts before taking the pills, and found them easy to understand and able to address most questions. However, there was a desire for more information on any longer term effects. Despite their expectations, fewer than half of the participants reported side effects, many mild. In many cases the need to use EC had made the participants more consistent in their use of contraceptives, often with increased partner involvement. Despite their awareness of contraceptive availability, many of the women in the study showed limited knowledge of menstruation, contraception and general reproductive health. This study has highlighted some drawbacks of pharmacist involvement and suggests that despite misgivings over misuse, EC would operate best as a purely OTC product, as is already the case in Norway, where women or their partners can buy EC without embarrassment and read the instructions in the privacy of their own homes.1
1. Gainer E, Blum J, Toverud E-L, et al. Bringing emergency contraception over the counter: experiences of non-prescription users in France, Norway, Sweden and Portugal. Contraception 2003:68:117–24.