Background

A myriad of interventions exist to treat postpartum hemorrhage (PPH), ranging from uterotonics and hemostatics to surgical and aortic compression devices. Nonetheless, PPH remains the leading cause of maternal mortality worldwide. The purpose of this article is to review the available evidence on the efficacy of misoprostol for the treatment of primary PPH and discuss implications for health care planning.

Data and methods

Using PubMed, Web of Science, and GoogleScholar, we reviewed the literature on randomized controlled trials of interventions to treat PPH with misoprostol and non-randomized field trials with controls. We discuss the current knowledge and implications for health care planning, especially in resource-poor settings.

Results

The treatment of PPH with 800 μg of misoprostol is equivalent to 40 IU of intravenous oxytocin in women who have received oxytocin for the prevention of PPH. The same dose might be an option for the treatment of PPH in women who did not receive oxytocin for the prevention of PPH and do not have access to oxytocin for treatment. Adding misoprostol to standard uterotonics has no additional benefits to women being treated for PPH, but the beneficial adjunctive role of misoprostol to conventional uterotonics is important in reducing intra- and postoperative hemorrhage during cesarean section.

Conclusion

Misoprostol is an effective uterotonic agent in the treatment of PPH. Clinical guidelines and treatment protocols should be updated to reflect the current knowledge on the efficacy of misoprostol for the treatment of PPH with 800 μg sublingually.

CONTEXT: Provision of high-quality contraceptive counseling and services is essential to ensure family planning (FP) programs are rights-based and voluntary. Togos modern contraceptive use has steadily increased with almost a quarter of the method mix attributed to long-acting reversible contraceptives (LARC). The purpose of this study is to assess the quality of LARC provision in Togo. METHODS: Data for this study were collected in 2016 as part of a larger research study conducted in Lomé, Togo to assess the effectiveness of the ongoing FP service delivery model. Quality of FP service was assessed in terms of program capacity and program performance. Program capacity was measured with five individual variables and program performance was measured with the Method Information Index (MII). Descriptive statistics and mixed effects models were used to assess likelihood of LARC uptake. RESULTS: Of the 669 clients included in the study, 19.4% received a LARC method. Multivariable results show that LARC uptake is significantly associated with supervisory visit at the facility in the last three months (program capacity indicator) (OR 1.44; 95%CI 1.48-2.39) and is twice as likely for those with a positive MII score, even after controlling for provider and client characteristics (OR 2.1; 95%CI 1.61-2.51). CONCLUSION: This study identified supervisory visits and comprehensive contraceptive counseling as the key quality factors positively associated with uptake of LARC. Continued focus on quality of care and provider-client information exchange is necessary to ensure womens FP needs are met.

Background

Postpartum hemorrhage (PPH) is the leading cause of maternal death in low-income countries and is the primary cause of approximately one-quarter of global maternal deaths. The purpose of this paper is to provide a review of PPH prevention interventions, with a particular focus on misoprostol, and the challenges and opportunities that preventing PPH in low-resource settings presents.

Methods

Using PubMed, we conducted a review of the literature on the randomized controlled trials of interventions to prevent PPH. We then searched PubMed and Google Scholar for nonrandomized field trials of interventions to prevent PPH. We limited our review to interventions that are discussed in the current World Health Organization (WHO) recommendations for PPH prevention and present evidence regarding the use of these interventions. We focused our review on nondrug PPH prevention interventions compared with no intervention and uterotonics versus placebo; this review does not decipher the relative effectiveness of uterotonic drugs. We describe challenges to and opportunities for scaling up PPH prevention interventions.

Results

Active management of the third stage of labor is considered the "gold standard" strategy for reducing the incidence of PPH. It combines nondrug interventions (controlled cord traction and cord clamping) with the administration of an uterotonic drug, the preferred uterotonic being oxytocin. Unfortunately, oxytocin has limited application in resource-poor countries, due to its heat instability and required administration by a skilled provider. New heat-stable drugs and drug formulations are currently in development that may improve the prevention of PPH; however, misoprostol is a viable option for provision at home by a lay health care worker or the woman herself, in the interim.

Conclusion

As the main cause of maternal mortality worldwide, PPH prevention interventions need to be prioritized. Increased access to prophylactic uterotonics, regardless of where deliveries occur, should be the primary means of reducing the burden of this complication.

Background

In Togo, men who have sex with men (MSM) experience disproportionately high rates of human immuno-deficiency virus (HIV), with prevalence at 13% compared to the countrywide general HIV prevalence of 2.5%. Mobile phone adoption has grown rapidly in West Africa in recent years and mobile health (mHealth) provides an opportunity to engage high-risk populations in HIV prevention, treatment and care (PTC). This study focuses on the text messaging component of a mHealth program and resulting linkages to PTC in Lomé, Togo.

Methods

We used a mixed-methods approach to collect information directly from a purposive sample of MSM to estimate the potential impact of the mHealth intervention on specific outcomes. A structured survey captured 503 MSM experiences with program activities to increase access to PTC through short message system (SMS), including data on socio-demographics, HIV knowledge and testing history, program awareness, use of services and referrals, use of mHealth, and experiences with and preferences for receiving HIV SMS messages. Twelve in-depth interviews captured qualitative data on MSM experiences and opinions related to the mHealth intervention, as well as barriers and facilitators to linkages between mHealth and clinic services.

Results

Predicted probabilities of MSM being reached by the program and linked to PTC is higher for those exposed to the program and significantly different (P<0.001). The probability of being linked to HIV prevention emerges as the highest among MSM exposed to SMS messages with 92% probability. MSM exposed to SMS had a 63% probability to be linked to treatment compared to only 40% among those not exposed to SMS. Program barriers and facilitators were identified through the thematic analysis of the qualitative data. Several facilitators to PTC were reported including: increased knowledge and awareness; convenient location of HIV testing coupled with distribution of products; ensuring individual confidentiality; and perceived care of providers. The main barriers to the program were lack of program awareness, program functionality and affordability for referral services, and peer educator training.

Conclusions

The probability of being reached, and adhering to PTC is significantly higher among MSM exposed to HIV related SMS messages; however, the usefulness of SMS in HIV programs targeting MSM needs to be better understood.

Ethiopia has made notable progress in increasing awareness and knowledge of family planning and is considered a success story among funders and program planners. Yet unmet need among rural women (28.6%) is almost double that of urban women (15.5%), with a wide gap in total fertility rate depending on urban (2.6) or rural (5.5) residence. This study investigates the impact of a service delivery model that combines community-based distribution (CBD) of contraception with social marketing in Tigray, Ethiopia, to create a more sustainable approach to CBD. Between September 2011 and October 2013, 626 volunteer CHWs were recruited and trained to administer depot medroxyprogesterone acetate (DMPA) injections and provide counseling and referrals to the health post for other methods; the project implementation period ended in June 2014. The CHWs received a supply of DMPA injections in the form of a microloan from a drug revolving fund; the CHWs charged women a minimal fee (5 birr, or US$0.29), determined based on willingness-to-pay data, for each DMPA injection; and the CHWs returned part of the fee (3 birr) to the drug revolving fund while keeping the remaining portion (2 birr). The CHWs also promoted demand for family planning through door-to-door outreach and community meetings. Existing health extension workers (HEWs) provided regular supervision of the CHWs, supplemented by in-depth supervision visits from study coordinators. Baseline and endline representative surveys of women of reproductive age, as well as of participating CHWs, were conducted. In addition, DMPA provision data from the CHWs were collected. Between October 2011 and June 2014, the CHWs served in total 8,604 women and administered an estimated 15,410 DMPA injections, equivalent to providing 3,853 couple-years of protection. There was a 25% significant increase in contraceptive use among surveyed women, from 30.1% at baseline to 37.7% at endline, with DMPA use largely responsible for this increase. Changes in quality of family planning markers from baseline suggested services improved between baseline and endline: nearly 50% more women reported being told about side effects and what to do if they experience side effects, and 25% more women said they were told about other methods of contraception. The results from household surveys at baseline and endline suggest that CHWs in this model made a significant contribution to family planning in the region.

BACKGROUND: In the United States, the internet is widely used to seek health information. Despite an estimated 18 million Google searches on abortion per year and the demonstrated importance of the abortion pill as an option for pregnancy termination, the top webpage search results for abortion pill searches, as well as the content and quality of those webpages, are not well understood. METHODS: We used Googles Custom Search Application Programming Interface (API) to identify the top 10 webpages presented for abortion pill searches on August 06, 2018. We developed a comprehensive, evidence-based Family Planning Webpage Quality Assessment Tool (FPWQAT), which was used to assess webpage quality for the five top webpages presenting text-based educational content. RESULTS: Of the top webpages for abortion pill searches, a plannedparenthood.com page was the top result and scored highest on our assessment (81%), providing high-quality and useable information. The other four webpages, a Wikipedia.com page and three anti-abortion information webpages, scored much lower on our assessment (14%-43%). These four webpages had lower quality of information in less useable formats. The anti-abortion pages also presented a variety of disinformation about the abortion pill. CONCLUSIONS: Both the lack of accurate clinical content on the majority of top webpages and the concerning disinformation they contained raise concerns about the quality of online abortion pill information, while underlining challenges posed by Google search results to informed choice for consumers. Healthcare providers and consumers must be informed of online abortion pill content that is not based in current clinical evidence, while advocates and policymakers should push for online information that is credible and useable. These changes are imperative given the importance of sound abortion pill information for reproductive decision-making at a time when in-person abortion services are further challenged in the US.

Abortion stigma is influenced by a variety of factors. Previous research has documented a range of contributors to stigma, but the influence of perceived social norms about contraception has not been significantly investigated. This study assesses the influence of perceived social norms about contraception on abortion stigma among women in Luanda, Angola. This analysis uses data from the 2012 Angolan Community Family Planning Survey. Researchers employed multi-stage random sampling to collect demographic, social, and reproductive information from a representative sample of Luandan women aged 15-49. Researchers analyzed data from 1469 respondents using chi-square and multiple logistic regression. Researchers analyzed womens perceptions of how their partners, friends, communities, and the media perceived contraception, and examined associations between those perceptions and respondents abortion stigma. Stigma was approximated by likelihood to help someone get an abortion, likelihood to help someone who needed medical attention after an abortion, and likelihood to avoid disclosing abortion experience. Higher levels of partner engagement in family planning discussion were associated with increased stigma on two of the three outcome measures, while higher levels of partner support of contraception were associated with decreased stigma. Perceived community acceptance of family planning and media discussion of family planning were associated with a decrease in likelihood to help someone receive an abortion. These results suggest that increasing partner support of family planning may be one strategy to help reduce abortion stigma. Results also suggest that some abortion stigma in Angola stems not from abortion itself, but rather from judgment about socially unacceptable pregnancies.

Background

In Sub-Saharan Africa, policy changes have begun to pave the way for community distribution of injectable contraceptives but sustaining such efforts remains challenging. Combining social marketing with community-based distribution provides an opportunity to recover some program costs and compensate workers with proceeds from contraceptive sales. This paper proposes a model for increasing access to injectable contraceptives in rural settings by using community-based distributers as social marketing agents and incorporating financing systems to improve sustainability.

Methods

This intervention was implemented in three districts of the Central Zone of Tigray, Ethiopia and program data has been collected from November 2011 through October 2012. A total of 137 Community Based Reproductive Health Agents (CBRHAs) were trained to provide injectable contraceptives and were provided with a loan of 25 injectable contraceptives from a drug revolving fund, created with project funds. The price of a single dose credited to a CBRHA was 3 birr ($0.17) and they provide injections to women for 5 birr ($0.29), determined with willingness-to-pay data. Social marketing was used to create awareness and generate demand. Both quantitative and qualitative methods were used to examine important feasibility aspects of the intervention.

Results

Forty-four percent of CBRHAs were providing family planning methods at the time of the training and 96% believed providing injectable contraceptives would improve their services. By October 2012, 137 CBRHAs had successfully completed training and provided 2541 injections. Of total injections, 47% were provided to new users of injectable contraceptives. Approximately 31% of injections were given for free to the poorest women, including adolescents.

Conclusions

Insights gained from the first year of implementation of the model provide a framework for further expansion in Tigray, Ethiopia. Our experience highlights how program planners can tailor interventions to match family planning preferences and create more sustainable contraceptive service provision with greater impact.

Mozambique has witnessed a climbing total fertility rate in the last 20 years. Nearly one-third of married women have an unmet need for family planning, but the supply of family planning services is not meeting the demand. This study aimed to explore the safety and effectiveness of training 2 cadres of community health workers-traditional birth attendants (TBAs) and agentes polivalentes elementares (APEs) (polyvalent elementary health workers)-to administer the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), and to provide evidence to policy makers on the feasibility of expanding community-based distribution of DMPA in areas where TBAs and APEs are present. A total of 1,432 women enrolled in the study between February 2014 and April 2015. The majority (63% to 66%) of women in the study started using contraception for the first time during the study period, and most women (over 66%) did not report side effects at the 3-month and 6-month follow-up visits. Very few (less than 0.5%) experienced morbidities at the injection site on the arm. Satisfaction with the performance of TBAs and APEs was high and improved over the study period. Overall, the project showed a high continuation rate (81.1%) after 3 injections, with TBA clients having significantly higher continuation rates than APE clients after 3 months and after 6 months. Clients' reported willingness to pay for DMPA (64%) highlights the latent demand for modern contraceptives. Given Mozambique's largely rural population and critical health care workforce shortage, community-based provision of family planning in general and of injectable contraceptives in particular, which has been shown to be safe, effective, and acceptable, is of crucial importance. This study demonstrates that community-based distribution of injectable contraceptives can provide access to family planning to a large group of women that previously had little or no access.

Background

Despite improvements in contraception availability, women face persistent barriers that compromise reproductive autonomy and informed choice. Provider bias is one way in which access to contraception can be restricted within clinical encounters and has been established as common in sub-Saharan Africa. This analysis assessed the prevalence of provider restrictions and the potential impact on women's method uptake in Lomé, Togo.

Methods

This sub-analysis used survey data from provider and client interviews collected to assess the impacts of the Agir pour la Planification Familiale (AgirPF) program in Togo. The relationships between provider restrictiveness and women's receipt of their desired method of contraception were modelled using mixed effects logistic regressions looking at all women and among subgroups hypothesized to be at potentially higher risk of bias.

Results

Around 84% of providers reported a restriction in contraceptive provision for the five contraceptive methods explored (pill, male condom, injectable, IUD, and implant). Around 53% of providers reported restricting at least four of the five methods based on age, parity, partner consent, or marital status. Among all women, there were no significant associations between provider restrictiveness and women's receipt of desired method, including among those who desired long-acting methods. In adjusted modeling, marital status was a covariate significantly associated with desired method, with married women more likely to receive their desired method than unmarried women (aOR 2.73, 95% CI 1.45-5.13).

Conclusion

Provider reports of high levels of restrictions in this population are concerning and should be further explored, especially its effects on unmarried women. However, restrictions reported by providers in this study did not appear to statistically significantly influence contraceptive method received.