Women In Low-resource Settings Research Articles

Intimate Partner Violence and Uptake of Antenatal Care: A Scoping Review of Low- and Middle-Income Country Studies.

Intimate partner violence (IPV) is associated with negative physical and mental health outcomes. Antenatal care can act as a link to IPV services, but experiencing IPV may be associated with reduced uptake of antenatal care, an issue that has received little attention from researchers. A scoping review was conducted to synthesize quantitative research on IPV and uptake of antenatal care in low-resource settings. Keyword searches of PubMed and other databases and snowball searches of reference lists were conducted to identify articles published in 2005-2015 that measured one or more types of IPV (physical, sexual or emotional) or controlling behavior and assessed the relationship of such abuse with use of antenatal care. For each identified article, key characteristics and findings were abstracted, and study quality was assessed. Sixteen articles, representing 10 low- and middle-income countries, met the inclusion criteria. Most studies were of medium-to-high quality but low rigor, reflecting the abundance of cross-sectional studies in the literature. In all 16 studies, IPV was negatively associated with initiation of antenatal care, number of visits or use of a skilled provider. Analyses revealed reduced odds of antenatal care use among women who had experienced IPV (odds ratios, 0.5-0.8) and elevated odds of antenatal care use among women who had not experienced IPV or of nonuse among women who had experienced IPV (1.2-4.1). Women in low-resource settings who experience IPV have a reduced likelihood of obtaining optimal antenatal care and may benefit from interventions to mitigate barriers to care.

Accuracy of triage strategies for human papillomavirus DNA-positive women in low-resource settings: A cross-sectional study in China.

CareHPV is a human papillomavirus (HPV) DNA test for low-resource settings (LRS). This study assesses optimum triage strategies for careHPV-positive women in LRS. A total of 2,530 Chinese women were concurrently screened for cervical cancer with visual inspection with acetic acid (VIA), liquid-based cytology and HPV testing by physician- and self-collected careHPV, and physician-collected Hybrid Capture 2 (HC2). Screen-positive women were referred to colposcopy with biopsy and endocervical curettage as necessary. HPV-positivity was defined as ≥1.0 relative light units/cutoff (RLU/CO) for both careHPV and HC2. Primary physician-HC2, physician-careHPV and self-careHPV and in sequential screening with cytology, VIA, or increased HPV test-positivity performance, stratified by age, were assessed for cervical intraepithelial neoplasia (CIN) grade 2/3 or worse (CIN2/3+) detection. The sensitivities and specificities of primary HPV testing for CIN2+ were: 83.8%, 88.1% for physician-careHPV; 72.1%, 88.2% for self-careHPV; and 97.1%, 86.0% for HC2. Physician-careHPV test-positive women with VIA triage had a sensitivity of 30.9% for CIN2+ versus 80.9% with cytology triage. Self-careHPV test-positive women with VIA triage was 26.5% versus 66.2% with cytology triage. The sensitivity of HC2 test-positive women with VIA triage was 38.2% versus 92.6% with cytology triage. The sensitivity of physician-careHPV testing for CIN2+ decreased from 83.8% at ≥1.0 RLU/CO to 72.1% at ≥10.00 RLU/CO, while the sensitivity of self-careHPV testing decreased from 72.1% at ≥1.0 RLU/CO to 32.4% at ≥10.00 RLU/CO; similar trends were seen with age-stratification. VIA and cytology triage improved specificity for CIN2/3 than no triage. Sensitivity with VIA triage was unsuitable for a mass-screening program. VIA provider training might improve this strategy. Cytology triage could be feasible where a high-quality cytology program exists. Triage of HPV test-positive women by increased test positivity cutoff adds another LRS triage option.

Accuracy of triage strategies for human papillomavirus DNA-positive women in low-resource settings: A cross-sectional study in China

Accuracy of triage strategies for human papillomavirus DNA-positive women in low-resource settings: A cross-sectional study in China

Reproducibility of p16INK4a Biomarker Levels, as Measured by ELISA, Among HIV-Positive Women in Western Kenya With Normal Cervical Exams During a 12-Month Follow-Up

Abstract 42 Background: Cervical cancer disproportionately affects women in low- and middle-income countries (LMICs), and cytology-based programs are not feasible for use in these settings. This has prompted a search for alternative cervical-cancer screening or surveillance methods that can be adopted in LMICs to address the high disease burden. In this study, we seek to evaluate the performance and reliability of cervical p16INK4a biomarker as measured by an ELISA assay among a group of HIV-positive women in a low-resource setting who had normal screening results by gold standard at baseline and at 12-month follow-up. Methods: This prospective study took place at the Family AIDS Care and Education Services (FACES) clinic in Kisumu, Kenya. Participants underwent cervical cancer screening using VIA, colposcopy and collection of cervical HPV p16INK4a samples. Women with negative colposcopies were rescreened at 12-months, and cervical p16INK4a samples were collected. Among women with negative colposcopies at both baseline and follow-up, we investigated the reproducibility of p16INK4a biomarker levels within the same woman between the two visits. Biomarker levels were determined using an ELISA-based biochemical assay. We compared median p16INK4a levels between baseline and follow-up using the paired t-test. We also examined correlation using correlation coefficients and a Bland-Atman plot of differences versus average. A multivariate regression model was fit to identify demographic and clinical variables associated with absolute change in p16INK4a levels. Results: Among the ninety-three women who had normal cervical exams, mean p16INK4a levels increased significantly between baseline and follow-up period, at 20.2 U/ml vs 30.1 U/ml (p<0.01). The correlation coefficient between the values at the two time points was 0.61 (p<0.01), indicating a moderate but not perfect agreement between baseline and follow-up biomarker levels. A Bland-Altman plot of difference versus average of the two measures showed a mean difference of 10 units/ml, indicating poor agreement between the two measurements. In a multivariate regression model including age at screening, HPV status, hormonal contraception use, use of ART, VIA results, and CD4 count at baseline and follow-up, only age at screening and HPV status were significantly associated with greater absolute change in p16INK4a measurements (p< 0.01). Conclusion: Our results suggest that there is variability in levels of p16INK4a biomarker as measured by ELISA in HIV-positive women in low-resource settings with normal screening as determined by colposcopy over a 12-month follow-up period. Biomarker levels varied significantly more among older women and those who were HPV positive at baseline, despite normal cervical exams. These data suggest that elevations in p16INK4a biomarker levels may not be a reliable marker of dysplasia in this group of women. Further research in this population as well as replication of these results will be important. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Chemtai Mungo No relationship to disclose Carol Conell No relationship to disclose May Maloba No relationship to disclose Elizabeth Bukusi No relationship to disclose Craig Cohen Consulting or Advisory Role: Symbiomix Inc. Megan Huchko No relationship to disclose

Cultural Influences in Women-Friendly Labor-Saving Hand Tool Designs: The Milk Churner Case.

Objective:The aim of this study was to highlight the importance of culture in sustainable, labor-saving solutions design for women in low-resource settings.Background:One of the reasons behind the gender asset gap among Sub-Saharan African women is the higher labor burden these women face, making it difficult for them to produce for the home and markets. Hand tools are the simplest form and therefore the best first step to address this problem. But designing women-friendly (sustainable) hand tools calls for better understanding of the low-resource settings where these women reside.Method:A milk churner was redesigned using a human-centered (participatory) approach with groups of women from two dominant ethnolinguistic groups of Bantu and Nilotic of Uganda, and its usability was tested.Results:The churner reduced labor up to eightfold and has potential to expand the range of uses to include children and husbands due to its simplicity. Also, the churner significantly reduced undesirable health effects, like pain in knee joints. Based on the experience with the churner, a six-item “survival guide” is proposed to complement human-centered design guiding principles for facilitating the generation of solutions in low-resource settings.Conclusion:By paying great attention to culture in relation to human factors, a labor-reducing churner has been successfully introduced among Ugandan women. The ultimate goal is to make the churner available to female smallholder dairy-farming households throughout Sub-Saharan Africa.Applications:This study provides a survival guide for generating solutions to problems from low-resource settings.

Factors influencing modes of transport and travel time for obstetric care: a mixed methods study in Zambia and Uganda.

Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight districts in Uganda and Zambia. Quantitative data were analysed using univariate statistics, and qualitative data were analysed using thematic content analysis techniques. On average, women spent 62-68 min travelling to a clinic for delivery. Very different patterns in modes of transport were observed in the two countries: 91% of Ugandan women employed motorized forms of transportation, while only 57% of women in Zambia did. Motorcycle taxis were the most commonly used in Uganda, while cars, trucks and taxis were the most commonly used mode of transportation in Zambia. Lower-income women were less likely to use motorized modes of transportation: in Zambia, women in the poorest quintile took 94 min to travel to a health facility, compared with 34 for the wealthiest quintile; this difference between quintiles was ∼50 min in Uganda. Focus group discussions confirmed that transport is a major challenge due to a number of factors we categorized as the 'three A's:' affordability, accessibility and adequacy of transport options. Women reported that all of these factors had influenced their decision not to deliver in a health facility. The two countries had markedly different patterns of transportation for obstetric care, and modes of transport and travel times varied dramatically by wealth quintile, which policymakers need to take into account when designing obstetric transport interventions.

A facility birth can be the time to start family planning: Postpartum intrauterine device experiences from six countries

Initiation of family planning at the time of birth is opportune, since few women in low-resource settings who give birth in a facility return for further care. Postpartum family planning (PPFP) and postpartum intrauterine device (PPIUD) services were integrated into maternal care in six low- and middle-income countries, applying an insertion technique developed in Paraguay. Facilities with high delivery volume were selected to integrate PPFP/PPIUD services into routine care. Effective PPFP/PPIUD integration requires training and mentoring those providers assisting women at the time of birth. Ongoing monitoring generated data for advocacy. The percentages of PPIUD acceptors ranged from 2.3% of women counseled in Pakistan to 5.8% in the Philippines. Rates of complications among women returning for follow-up were low. Expulsion rates were 3.7% in Pakistan, 3.6% in Ethiopia, and 1.7% in Guinea and the Philippines. Infection rates did not exceed 1.3%, and three countries recorded no cases. Offering PPFP/PPIUD at birth improves access to contraception.

Is Diversity in Agricultural Production Linked to Dietary Diversity Among Nepalese Women?

Evidence linking agricultural production diversity (APD) to dietary diversity is scarce, but constitutes a potentially important contributor to improving dietary adequacy among women in low resource settings. Using cross-sectional data for 4,508 married women from a national nutrition surveillance system across 21 districts in 3 agro-ecological zones in Nepal, we assessed the extent to which high and low APD were associated with women's dietary adequacy (WDDS > 5 food groups) using multivariate logistic regression (adjusting for household food security, socioeconomic status, education, and food expenditure). There were no differences in WDDS between women in non-agricultural households vs. women in households with low APD scores (1-4) in any zone. In the terai, women in households with high APD (5-10 food groups) were twice as likely to have adequate WDDS as women in non-agricultural households (OR: 2.05; 95% CI 1.21 – 3.47, p=0.008). In mountain and terai zones, women from households with high APD were 1.62 (95% CI 1.07 – 2.45, p=0.023) and 1.81 (95% CI 1.12 – 2.94, p=0.016) times more likely, respectively, to have adequate WDDS than women in low APD households. In the hills, household APD had no significant effect on WDDS. Increases in household food security, socioeconomic status, education, and food expenditure were also associated with increased WDDS in each region. APD was positively associated with adequate WDDS in the mountains and terai, supporting a hypothesis that increased agricultural diversity may help improve dietary diversity of women in households. Supported by the USAID through the Nutrition Innovation Lab (prime Tufts Univ) and a Borlaug Fellowship through Purdue University's Center for Global Food Security.

Adherence Partners are an Acceptable Intervention to Support Adherence to Prenatal Micronutrient Supplementation among Pregnant Women in Western Kenya

In populations with low calcium (Ca) intake, WHO now recommends providing prenatal Ca supplementation alongside iron‐folic acid (IFA) as part of antenatal care (ANC) services to reduce maternal mortality. Even when pregnant women have a stable supply of supplements, they often cite forgetting and family disapproval as adherence barriers. Adherence partners (AP) are a behavior change intervention that expands social support to improve adherence. Pregnant women select APs from their social network (e.g., a spouse or relative) and ask APs to encourage and remind them to take their supplements. This study assessed the acceptability of APs to improve adherence to prenatal Ca and IFA supplements in western Kenya through trials of improved practices, a formative research methodology that follows participants over time as they try a new behavior. We collected qualitative and quantitative data on acceptability and adherence during 3 interviews over 6 weeks. We provided 33 pregnant women with Ca and IFA supplements, counseling, and calendars, and then offered the option of selecting an AP; 26 women agreed to try an AP. Although many women in our previous formative research described husbands as unhelpful during pregnancy, 16 of 26 women selected their husbands to be their AP; most others chose female relatives. Participants reported APs supported adherence by encouraging, reminding, bringing supplements, and providing food. AP support of prenatal Ca and IFA supplements could be acceptable and helpful for pregnant women in low‐resource settings, even in the context of limited family support and ANC attendance. Further research is warranted to assess the appropriateness, feasibility, and impact of this low‐cost intervention.

Development of disulfiram-loaded vaginal rings for the localised treatment of cervical cancer

Cervical cancer is the third most prevalent cancer in women and disproportionately affects those in low resource settings due to limited programs for screening and prevention. In the developed world treatment for the disease in the non-metastasised state usually takes the form of surgical intervention and/or radiotherapy. In the developing world such techniques are less widely available. This paper describes the development of an intravaginal ring for the localised delivery of a chemotherapeutic drug to the cervix that has the potential to reduce the need for surgical intervention and will also provide a novel anti-cancer therapy for women in low resource settings. Disulfiram has demonstrated antineoplastic action against prostate, breast and lung cancer. Both PEVA and silicone elastomer were investigated for suitability as materials in the manufacture of DSF eluting intravaginal rings. DSF inhibited the curing process of the silicone elastomer, therefore PEVA was chosen as the material to manufacture the DSF-loaded vaginal rings. The vaginal rings had an excellent content uniformity while the DSF remained stable throughout the manufacturing process. Furthermore, the rings provided diffusion controlled release of DSF at levels well in excess of the IC50 value for the HeLa cervical cancer cell line.

Clinical characteristics associated with Mycoplasma genitalium among female sex workers in Nairobi, Kenya.

The prevalence of Mycoplasma genitalium is high in vulnerable populations of women in low-resource settings. However, the epidemiology of infection in these populations is not well established. To determine the prevalence of Mycoplasma genitalium and its association with cervical cytology and other correlates, we recruited 350 female sex workers (FSW) who were 18 to 50 years old in Nairobi, Kenya, for a cross-sectional study. A questionnaire was administered at baseline to obtain information on sociodemographics and sexual behaviors. Women underwent a pelvic exam, during which a physician collected cervical-exfoliation samples for conventional cytology and sexually transmitted infection (STI) testing. Samples were tested for M. genitalium and other STI organisms (Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis) and the E6/E7 mRNA of human papillomavirus (HPV) by Aptima nucleic amplification assays. The prevalence of M. genitalium was 12.9%. FSW who engaged in sexual intercourse during menses were less likely to have M. genitalium infection than those who did not (odds ratio [OR], 0.3; 95% confidence interval [95% CI], 0.1, 0.9). M. genitalium was also less prevalent among FSW who had worked in prostitution for >5 years (6.2%) than among those who had worked for <3 years (17.6%) (OR, 0.3; 95% CI, 0.1, 0.8). FSW who reported more frequent condom use were more likely to be infected with M. genitalium than those who reported less frequent use (OR, 3.8; 95% CI, 1.2, 11.6). These correlates differ from those found in M. genitalium studies conducted with FSW from West Africa and China. Further longitudinal analyses assessing associations with persistent M. genitalium infection are needed.

Acceptability of self-collection sampling for HPV-DNA testing in low-resource settings: a mixed methods approach.

BackgroundVaginal self-sampling with HPV-DNA tests is a promising primary screening method for cervical cancer. However, women’s experiences, concerns and the acceptability of such tests in low-resource settings remain unknown.MethodsIn India, Nicaragua, and Uganda, a mixed-method design was used to collect data from surveys (N = 3,863), qualitative interviews (N = 72; 20 providers and 52 women) and focus groups (N = 30 women) on women’s and providers’ experiences with self-sampling, women’s opinions of sampling at home, and their future needs.ResultsAmong surveyed women, 90% provided a self- collected sample. Of these, 75% reported it was easy, although 52% were initially concerned about hurting themselves and 24% were worried about not getting a good sample. Most surveyed women preferred self-sampling (78%). However it was not clear if they responded to the privacy of self-sampling or the convenience of avoiding a pelvic examination, or both. In follow-up interviews, most women reported that they didn’t mind self-sampling, but many preferred to have a provider collect the vaginal sample. Most women also preferred clinic-based screening (as opposed to home-based self-sampling), because the sample could be collected by a provider, women could receive treatment if needed, and the clinic was sanitary and provided privacy. Self-sampling acceptability was higher when providers prepared women through education, allowed women to examine the collection brush, and were present during the self-collection process. Among survey respondents, aids that would facilitate self-sampling in the future were: staff help (53%), additional images in the illustrated instructions (31%), and a chance to practice beforehand with a doll/model (26%).ConclusionSelf-and vaginal-sampling are widely acceptable among women in low-resource settings. Providers have a unique opportunity to educate and prepare women for self-sampling and be flexible in accommodating women’s preference for self-sampling.

A parallel study of careHPV and Hybrid Capture 2 human papillomavirus DNA testing for cervical cancer screening in rural China

Hybrid Capture 2 (HC2) has been demonstrated to be a feasible screening method for cervical cancer. Based upon HC2 technology, careHPV is a simple, rapid, accurate, and inexpensive screening test for women in low-resource settings. This study aims to characterize both the careHPV test and HC2 test, and to compare careHPV results of specimens stored in careHPV test collection medium (TCM) to HC2 results from partner specimens stored in Qiagen specimen transport medium and TCM. The positive rates of high-risk HPV in careHPV, HC2, and HC2 (TCM) were 13.2% (108/818), 13.2% (108/818), and 13.6% (111/818), respectively. The agreement rates of pairwise tests were 95.8% (95% CI: 94.5–97.2%), 96.7% (95% CI: 95.5–97.9%), and 97.2% (95% CI: 96.1–98.3%), respectively. The Kappa values of the pairwise tests were 0.82 (95% CI: 0.76–0.88), 0.86 (95% CI: 0.81–0.91), and 0.88 (95% CI: 0.83–0.93), respectively. Based on these findings, although careHPV is demonstrated to be a viable alternative to the HC2 test, improvements on the careHPV test are still required prior to its implementation as a suitable screening method for women in low-resource settings. Further studies on the significance and applicability of the careHPV test must be performed.

Role of Visual Inspection of Cervix with Acetic Acid (VIA) in Detecting Precancerous Lesions of Cervix

Background: Carcinoma of cervix is the most common malignancy in female and a major public health problem worldwide. It is the leading cause of death from cancer among women in low resource settings. In Bangladesh, mortality rate is high as most of the cases with cervical cancer are diagnosed in advanced stage. World Health Organization considers cervical cancer as a preventable disease as it can be identified in preinvasive stage. Considerable efforts have been given in detection and treatment of the condition all over the world. A number of cervical cancer screening tests are available. Among them, visual inspection of cervix with acetic acid is rational and can be competently performed by physicians with proper training. Objective: To find out the feasibility of the visual inspection of cervix with acetic acid for the detection of the precancerous lesions of the cervix in our country. Materials and Methods: This cross sectional, analytical study was carried out among the patients attending the outpatient department of Bangabandhu Sheikh Mujib Medical University (BSMMU) who were VIA positive and sent for colposcopy in the colposcopy clinic in the department of Obstetrics and Gynecology in BSMMU from June to December 2004. Two hundred samples were considered for this study. Results: Out of 200 cases, colposcopically 85% had CIN and invasive lesions, 4% had inflammatory lesions while 11% had normal findings. Colposcopy directed punch biopsy revealed positive lesions in 81%, 4% had inflammatory lesions while 15% had normal findings. Conclusion: The study concluded that VIA and colposcopy are the important methods in the evaluation of cervical premalignancy. VIA may be an important tool for screening of cervical cancer in low resource settings as it is simple, easy to perform and cost-effective. After screening, VIA positive cases must be referred for colposcopic evaluation. We can screen cervical cancer by VIA all over the country and thus reduce morbidity and mortality rate. DOI: http://dx.doi.org/10.3329/jemc.v4i1.18068 J Enam Med Col 2014; 4(1): 39-44

Birth of an Idea - Vouchers for Maternal Healthcare in India

Vouchers are used extensively for the provision of services such as education and healthcare across the globe. They entail numerous potential benefits such as freedom of choice, better targeting of vulnerable populations and improved quality and cost effectiveness of service delivery through provider competition. In the field of maternal healthcare services, vouchers present an excellent mechanism by which to overcome the financial, knowledge and socio-cultural barriers that prevent women in low resource settings from seeking institutionalized health care. This paper profiles voucher schemes implemented for maternal health care within India and discusses some of the challenges faced by these programmes. Suggestions for enhancing efficacy of voucher schemes have been made in the hope that they be incorporated within the policy framework of both existing and future initiatives.

P3.116 Risk Factors For Mycoplasma Genitalium Among Female Sex Workers in Nairobi, Kenya

BackgroundPrevalence of Mycoplasma genitalium is higher in vulnerable populations of women in low-resource settings; predictors for infection, however, are not well understood. This study aimed to determine the prevalence of...

Patient side cost and its predictors for cervical cancer in Ethiopia: a cross sectional hospital based study

BackgroundCervical cancer is a leading cause of death from cancer among women in low-resource settings, affecting women at a time of life when they are critical to social and economic stability. In addition, the economic burden is important for policy formulation. The aim of this study is to estimate patient side cost and to determine predictors of its variation for the treatment of cervical cancer.MethodsAnalytic cross sectional study involving 227 cervical cancer cases at Tikur Anbessa Hospital, Ethiopia was conducted. Cost estimation was based on patients' perspective and using the prevalence-based model as a time frame. Productivity losses were estimated from lost working days.ResultsThe mean outpatient cost per patient for cervical cancer was $407.2 (Median = $206.9). Direct outpatient cost (Mean = $334.2) takes the largest share compared with the indirect counterpart ($150). The outpatient cost for half of the respondent falls in a range between $93.7 and $478. The mean inpatient cost for hospitalized patients was $404.4. The average direct inpatient cost was $329 (74% medical costs and 26% non medical costs). The mean value for total inpatient cost for half of the respondents was in the range of $133.5 and $493.9. For every additional day of inpatient hospital stay, there is a daily incremental inpatient cost of $4.2.ConclusionAs has been found in other studies, our findings revealed that cervical cancer creates an immense financial burden on patients. Primary prevention measures, vaccination against HPV and screening, should be initiated and expanded to reduce morbidity from cervical cancer and subsequent costs in both human lives and money resources. Control of co-morbidity and complication should be emphasized during management of cervical cancer patients. Capacitating regional hospitals and provision of low cost or fee exemption schemes should be arranged and strengthened.

Criticism of misguided Chu et al. article

Chu, Brhlikova and Pollock's article suggests the WHO rethink its decision to include misoprostol on the Essential Medicines List. Their paper is a sad example of workers in an elite setting advocating policies with the potential to endanger the lives of thousands of vulnerable women in low-resource settings. The self-administration of misoprostol, or use by traditional birth attendants, is the most immediate and practical solution to help the least developed countries move towards achieving Millennium Development Goal 5.1 It is true that in some studies oxytocin performs marginally better than misoprostol,2 but as mentioned by Chu et al., oxytocin administration is not currently feasible in most low-resource settings. Misoprostol presents an opportunity to achieve some semblance of health equity.3 The paper is also methodologically and ethically flawed. It reviews the 172 published papers on the use of misoprostol to control postpartum haemorrhage (PPH) in the framework of high-quality obstetric services and it explicitly omits studies that are not randomized controlled trials (RCTs). However, RCTs are often impossible to conduct in most low-resource settings where maternal death rates are highest. The paper by Prata et al4. included in the review, in fact, was not an RCT. In the case of misoprostol, an undisputed powerful uterotonic, the most practical RCT would compare misoprostol to a placebo, since the reality in low-resource settings leaves only these two options. Consequently, a RCT would randomly allocate the risk of death to women in the control arm when we know that misoprostol might have the potential to save their lives. Since Chu et al. conducted their review; a RCT in Belgaum India found 400 μg sublingual misoprostol to be more effective than 10 IU intramuscular oxytocin, as measured by blood loss (mean blood loss 192 ± 124 mL with misoprostol and 366 ± 136 mL blood loss with oxytocin).5 These data, together with compelling literature from non-RCTs in low-resource settings, strongly endorse the WHO's decision, which weighed all of the evidence, with considerations of the larger context and implications. A reversal of their decision would only hurt the very women that Chu et al. purport to be helping.

Perceptions, Attitudes, and Self-Management of Natural Menopausal Symptoms in Ghanaian Women

The use of hormone replacement therapy (HRT) to alleviate menopausal symptoms is associated with risks of cardiovascular and thromboembolic diseases and breast cancer. In this qualitative study, we investigated how women in low-resource settings manage menopausal symptoms without HRT. We interviewed 34 menopausal Ghanaian women about their sources of information, perceptions, attitudes, and self-management methods for alleviating menopausal symptoms. The majority of the women used a combination of nonhormonal medications and complimentary and alternative medicine (CAM), including dietary modifications, exercise, and other lifestyle changes to effectively manage menopausal symptoms. Sources of information about menopause influenced participants’ perceptions, attitudes, and self-management choices.

Atypical squamous cells, cannot exclude high grade squamous intraepithelial (ASC-H) in HIV-positive women

Objective:South Africa has very high rates of both HIV infection and cervical pathology. The management of ASC-H is colposcopy and directed biopsy, but with so many women diagnosed with HSIL and a dearth of colposcopy centres in South Africa, women with cytologic diagnosis of ASC-H may not be prioritized for colposcopy. The aim of this study was to determine if HIV-positive women with a cytologic diagnosis of ASC-H should undergo immediate colposcopy or whether colposcopy can be delayed, within the context of an underfunded health care setting with so many competing health needs.Materials and Methods:A computer database search was performed from the archives of an NGO-administered clinic that offers comprehensive HIV care. All women with a cytologic diagnosis of ASC-H on cervical smears from September 2005 until August 2009 were identified. Histologic follow up was sought in all patients.Results:A total of 2111 cervical smears were performed and 41 diagnosed as ASC-H (1.94%). No histologic follow up data was available in 15 cases. Follow up histologic results were as follows: three negative (11.5%), five koilocytosis and/ or CIN1 (19.2%), ten CIN2 (38.5%) and eight CIN3 (30.8%). There were no cases of invasive carcinoma on follow up.Conclusion:The current appropriate management of HIV-positive women in low-resource settings with a diagnosis of ASC-H on cervical smear is colposcopy, despite the costs involved. In the future and if cost-effective in developing nations, use of novel markers may help select which HIV-positive women can be managed conservatively and which ones referred for more active treatment. More research in this regard is warranted.