ROUND-UP Service Delivery

Audit of abortion and post-abortion care in the UK

Approximately 180,000 abortions are performed annually in 324 units in England and Wales, around half carried out in NHS (National Health Service) hospitals, 22% under NHS funding agency agreements and 27% in private clinics. An audit questionnaire relating to level of care was sent to all providers and returned by 240 units, which between them are responsible for around 80% of the annual abortion procedures. The audit criteria used were derived from the draft recommendations in the Royal College of Obstetricians and Gynaecologists evidence-based clinical guideline, covering organisation of services, information, procedures, complications and after-care. The criteria included items such as the availability of a choice of relevant methods, time from enquiry to abortion, performance of necessary and unnecessary investigations, procedures relevant to length of pregnancy, future contraception advice and follow-up appointments. Choice of medical or surgical abortion was only offered in 33% of the units. Translators were available in 67% of units and female doctors in 60%. Provision for the visually- and hearing-impaired was generally poor. Written information on various aspects of abortion was provided by the majority of units, but a third failed to provide information relating to complications and half on confidentiality. Although 76% of providers (83% of NHS units) had acceptable policies relating to the prevention of post-abortion infection, only 32% routinely screened for both gonorrhoea and chlamydia. Routine cross-matching of blood, considered an unnecessary procedure, was carried out in 11% of mainly non-NHS facilities. Although most units were aware of current guidelines on speed of referral, only 66% reported adhering to them. The audit showed that general standards of care were appropriate but there were clear areas for improvement. Only half the units actually audit their procedures and complications. Costs could be reduced by stopping unnecessary investigations and maximising drug regimens by lowering dosages or considering alternatives.¹

• Thomas J, Paranjothy S, Templeton A. An audit of the management of induced abortion in England and Wales. International Journal of Gynecology and Obstetrics 2003;83:327–34.

Nepalese women flock to newly opened abortion clinic

Around 57,000 unsafe abortions were being performed in Nepal every year, resulting in complications responsible for at least 20% of maternal deaths. However, the recent legalisation of abortion up to 90 days of pregnancy (or up to 18 weeks if pregnancy resulted from rape) is beginning to address this problem as government abortion clinics are being set up. When the main government-run hospital in Kathmandu began offering termination of pregnancy at no cost earlier this year, within a month, they had counselled over 500 women and conducted 150 abortions. As a result of this success and growing demand, the government will be extending abortion facilities to six hospitals outside Kathmandu, first developing the necessary infrastructure and training doctors and nurses to carry out surgical abortion. It has also promised to provide abortion services in most district hospitals within a couple of years. However, it will be some time before the expansion of services is able to reach women in rural areas.¹

• Navhind Times on the Web, India. Nepal women flock to first government abortion clinic. 23 April 2004. At: 〈http://www.navhindtimes.com/PHPScripts/userlogin.php?URI=http〉.

Community-based involvement improves abortion care in rural South Africa

Since 1994 the Choice on Termination of Pregnancy Act has given South African women the legal right to terminate their pregnancies without requiring permission from medical professionals, husbands or others. However, quality abortion care is still mainly available in urban settings and used by those who can afford to pay privately. The fragmented and overburdened health-care system, combined with patriarchal and conservative values, a lack of medical sophistication among women and the physical distance between home and the nearest approved centre, means that the reality for rural women has barely changed. In Limpopo region a series of workshops has helped to mobilise the community to improve this situation. A range of religious and traditional leaders, hospital managers, health care workers, municipal councillors, mayors, teachers and staff from community-based organisations were brought together to examine access issues. Using group work, fictional case studies, self-assessment and information-sharing sessions focused on both practicalities and attitudes, the workshops highlighted the contrast between the ideals of the law and the everyday reality of unsafe abortions that women are forced to seek. The workshops identified many areas which prevent the appropriate implementation of the law and highlighted key needs, including the recognition of women's reproductive rights, increased tolerance of divergent views on abortion, a focus on quality of care for women seeking abortions, and the necessity to train more abortion providers. As a result of these workshops, 60 of the 92 midwives who attended volunteered to be trained, key members of the community became involved in the dissemination of relevant information on abortion and family planning, and more clinics have started offering abortion services. This demonstrates the importance of identifying and recruiting community-based stakeholders in developing and delivering local strategies to increase access to high quality abortion care.¹

• Trueman K. Finding community-based solutions for overcoming barriers to safe abortion care in rural South Africa. Dialogue 2003;7(1). At: 〈www.ipas.org〉.

Abortions common but illegal in Egypt

Abortion is illegal in Egypt unless the woman's life is in imminent danger. Damage to the fetus is not accepted as a reason for abortion, a legal position emphasised by a recent fatwa that says that “it is impermissible for the mother to induce abortion [even] if it is proven that the fetus is deformed or suffers from mental retardation… It is not a justifiable excuse”. Nevertheless, women regularly find ways to end unwanted pregnancies. A 1996 study among 1,300 Egyptian women by the Cairo Demographic Centre found that one-third had attempted to terminate a pregnancy. Other studies suggest that about one-third of abortions are carried out without medical supervision, with women trying traditional remedies or overdoses of aspirin or quinine, at a risk to their own lives. Many foreign-trained Egyptian gynaecologists now offer abortions in private clinics, although these relatively safe procedures, costing as high as US$460, are not affordable for most women. Although a physician who performs an abortion could face three years in prison, the financial gains often outweigh the risks. For US$150 many doctors or midwives will perform abortions but sometimes in far less sanitary conditions or with outdated methods.¹

• Alker C. Abortions are illegal and common in Egypt. Women's Enews (USA). 12 April 2004. At: 〈http://www.womensenews.org/article.cfm/dyn/aid/1785/context/archive〉.

Preventing congenital syphilis

Congenital syphilis may affect up to one million pregnancies a year in developing countries, yet this significant public health problem appears to have been forgotten. This editorial and series of seven articles revisit the problem and consider how solutions could be advanced. They highlight areas such as the lack of appreciation of the burden of congenital syphilis, syphilis control not being part of national policy and the difficulties in implementing appropriate screening and treatment where policies exist. There is a need to encourage women to attend clinics early in their pregnancy, to perform screening tests locally and to treat both the woman and her sexual partner(s). Improvements in screening tests make it easier to test at primary facilities, but a broader approach to control of congenital syphilis may be required. Penicillin, the mainstay of treatment, is both cheap and effective, and was successful in reducing the prevalence of syphilis in Uganda when people aged 15–49 were mass treated. It is therefore probable that routine treatment of all pregnant women in a high prevalence area would achieve a similar effect in a cost-effective manner. Together, the articles emphasise the need to integrate traditional, effective measures into overall policy and to consider and evaluate alternative approaches. International health agencies need to tackle the control of syphilis and specifically congenital syphilis.^1,2

• Walker DG, Walker GJA. Prevention of congenital syphilis–time for action [Editorial]. Bulletin of World Health Organization 2004;82(6):401; and articles at p.402–446. All available at: 〈www.who.int/bulletin〉.

Contaminated powdered infant formula poses a threat to high-risk babies

A recent meeting has warned those caring for infants at high risk of infection that powdered infant formula is not sterile. It is not currently possible to produce commercially sterile powders, but most contaminants are harmless or found in insufficient numbers to cause disease. Contamination with E. sakazakii and Salmonella has been reported in infant formula and the former has been implicated in cases of infection and illness. Neonates up to four weeks of age and pre-term, low birthweight or immuno-compromised infants are at greatest risk. A summary report of the joint FAO/WHO workshop on bacteria in powdered infant formula can be found at: 〈http://www.who.int/foodsafety/micro/meetings/feb2004/en/〉.¹

• Mayor S. FAO/WHO meeting warns of contamination of powdered infant formula. BMJ 2004;328:426.

Male doctors reject obstetrics and gynaecology in the UK

In 1975 around 4% of UK medical school graduates, both men and women, stated that obstetrics and gynaecology were their first preference for a career. By 2000 this had fallen to only 0.9% of men and 3.2% of women, which may exacerbate the shortage of physicians in the field. This study of 529 male and 507 female undergraduates shows that male students received significantly less clinical experience than female students in a range of obstetric and gynaecological procedures, such as performing and observing normal deliveries, speculum and pelvic examinations, and cervical smears. A perceived anti-male environment in obstetrics and gynaecology may also be a reason why men reject careers in this field. These problems could lead not only to a serious shortfall in specialists, but could discourage men from involvement in contraception, well-woman screening and gynaecological problems in general practice.¹

• Higham J, Steer PJ. Gender gap in undergraduate experience and performance in obstetrics and gynaecology: analysis of clinical experience logs. BMJ 2004;328:142–43.

Gender constraints in recruiting women health workers in Pakistan

Gender and social constraints make it difficult for women in Pakistan to access health services. Aware of the problem, the government has attempted to employ large numbers of woman as health and family planning workers. However, data for 1996 show that 60% of such positions were not filled, meaning that only 16% of eligible women had been visited by a fieldworker. The training and retention of Lady Health Workers (LHW) and Lady Health Visitors (LHV) is difficult, mainly because the same constraints which make access to health care a problem for all women also operate for women health workers. This is manifested in a number of ways: the hierarchical management structure does not offer careers for women; there is general disrespect from male colleagues, which often includes a high level of sexual harassment; woman's ability to do the job is restricted by the need to travel alone on pubic transport; there is considerable conflict between domestic and work responsibilities, as working outside the home is often considered dishonourable; and finally there is poor infrastructural support. Although changes will not be easy, unless these problems are addressed from the highest levels of management, the Pakistani government will remain unsuccessful in recruiting women health workers.¹

• Mumtaz Z, Salway S, Waseem M, et al. Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy and Planning 2003;18(3):261–69.

Midwife-led care in Nepal

Midwifery care in Nepal, as elsewhere, is frequently thought to be doctor-led, an assumption which is reflected in midwifery training. Yet, in reality, midwives in the field often work autonomously, only referring to doctors for complicated cases. So that midwifery training would reflect the true situation, the Patan Hospital Birthing Centre offers in-service training in which midwives deal with all low-risk deliveries, referring only complicated cases to the local hospital. A study comparing their outcomes with those of a consultant-led maternity unit concluded that the midwife-led unit was as effective in providing appropriate care for low-risk deliveries and scored better in associated reproductive health areas. The study found no significant differences between the two types of unit in terms of the duration or complications of labour, the mode of delivery, birthweight, neonatal Apgar score or admission to the special care baby unit. Some procedures varied between the two units, with artificial rupture of membranes being more likely and augmentation of labour with oxytocin and episiotomy less likely in the midwife-led unit. Women in the midwife-led unit were also more likely to attend both post-natal and family planning clinics. Thus midwife-led care appears to lead to lower rates of iatrogenic procedures for low-risk patients, and could usefully be provided on a larger scale.¹

• Rana TG, Rajopadhyaya R, Bajracharya B, et al. Comparison of midwifery-led and consultant-led maternity care for low risk deliveries in Nepal. Health Policy and Planning 2003:18(3):330–37.

Financial implications of obstetric care for families in Benin and Ghana

Although hospital-based care for both normal and complicated deliveries is often free or set at a low fee in African countries, there are a number of hidden costs which may affect a woman's decision to choose a hospital birth or to seek hospital delivery when complications arise. Such costs include travel to the health care facility, costs relating to accompanying relatives, food and lodging, medicines, diagnostic tests and fixed charges for surgical or other medical interventions. In Ghana a spontaneous vaginal delivery costs around US$18, but for those with complications, such as anaemia, hypertension, haemorrhage, sepsis or dystocia, costs normally vary between $52 and $115 but go as high as $210. There is little difference in the costs of spontaneous deliveries between teaching and non-teaching hospitals, but where there are complications teaching hospitals are often more expensive. In Benin, the figures are around $34 for a spontaneous vaginal delivery in a teaching hospital but only $15 in a non-teaching hospital. As in Ghana, the costs in Benin rose for those with complications, with a norm between $56 and $256, and were higher in teaching than non-teaching hospitals. These costs are not insignificant. They account for 4–5% of annual household cash expenditure in Ghana and 15–20% in Benin. Thus, the economic burden of hospital-based delivery care is a significant factor in the choice of place of delivery for a woman and when complications arise, has a enormous impact on the household budget.¹

• Borghi J, Hanson K, Acquah C, et al. Costs of near-miss obstetric complications for women and their families in Benin and Ghana. Health Policy and Planning 2003;18(4):383–90.

Japanese women not taking up the birth control pill

Although the birth control pill was legalised five years ago in Japan, uptake has been low with only 1.3% of the 28 million Japanese women of childbearing age using it. The reasons for this are varied but the fact that the pill is a prescription drug and therefore cannot be advertised may be relevant. Other factors may include conservatism, vague concerns about possible side effects and an unwillingness to take a daily pill. Although experts in Japan emphasise that the pill is safe and more effective than other methods, the idea that contraception is a woman's responsibility is not widespread in Japan and the level of understanding regarding the pill remains low. The most common method of birth control is the condom, which has the advantage of protecting against STIs and HIV. Some experts argue that an increase in pill usage might be at the expense of condom usage and hence result in an upsurge in STIs and HIV.¹

• CNN. Japanese women shun the pill: five years after legalization, usage at 1.3 percent. 10 August 2004. At: 〈http://www.cnn.com/2004/HEALTH/08/10/japan.pill.ap/index.html〉.

Call for increased attention to STIs other than HIV

Many sexually transmitted infections remain undiagnosed because symptoms are minor or absent, and social stigma prevents people seeking health care. These hidden diseases have a high burden of morbidity, including many cases of infertility following pelvic inflammatory disease, ectopic pregnancy, cervical cancer and psychosexual dysfunction. Most infections are easily detectable, though some tests are expensive. Bacterial infections are curable and there are prospects for vaccines for gonorrhoea and papillomaviruses and for new treatments for viral infections. This excellent review details the problems, current status, diagnostic advances, management trends and future prospects for the most important bacterial and viral STIs, and argues for increased awareness and control of STIs. This will require a broad health sector response with adequate resourcing and a change in social and political attitudes.¹

• Donovan B. Sexually transmissible infections other than HIV. Lancet 2004;363:545–56.

UK may switch to liquid-based cytology for cervical cancer screening

The Pap smear test requires a sample of cells to be collected from the cervix, spread onto a glass slide and then fixed before being sent off for examination. The procedure produces a high number of samples unsuitable for testing. In liquid-based cytology the device used to collect the cell sample is rinsed off into a vial of preservative fluid and the slide prepared in the laboratory. Pilot studies suggest that this change will reduce the rate of inadequate smears from 9% to 1.5% and reduce the waiting time for test results from eight to two weeks. Cervical screening frequency in the UK is also being changed, with first tests now being offered at age 25, followed by three-yearly screens until the age of 50 and then five-yearly until the age of 65.¹

• Mayor S. NHS cervical screening programme to introduce liquid based cytology [News roundup]. BMJ 2003;327(7421):948.

US women with STIs interested in advanced provision of emergency contraception

While many family planning programmes have successfully integrated STI screening into their routine practice, the reverse is not true, i.e. STI control programmes have rarely incorporated family planning services. A study of 548 American women with gonorrhoea and/or chlamydia found very high rates of past unintended pregnancy and, in a large minority, a significant risk of future unintended pregnancy. When those not using contraception or using condoms on their own were offered information about contraception and assistance arranging an appointment at a family planning clinic, only 15% (31/165) accepted the offer of information. 6% (8/127) requested an appointment but only three of them actually kept the appointment. However, when advanced provision of emergency contraception (EC) was discussed, 81% (87/107) said they would like to have EC at home in case they had unprotected sex, whereas only 14% (15/107) said they would not want it. This suggests that the offer of EC to women presenting with STIs could be of value in preventing unwanted pregnancies.¹

• Golden MR, Whittington WLH, Handsfield HH, et al. Failure of family-planning referral and high interest in advanced provision emergency contraception among women contacted for STD partner notification. Contraception 2004;69:241–46.