Underuse of modern methods of contraception: underlying causes and consequent undesired pregnancies in 35 low- and middle-income countries

Study question: What is the contribution of the underuse of modern methods (MM) of contraception to the annual undesired pregnancies in 35 low- and middle-income countries? Summary answer: Fifteen million out of 16.7 million undesired pregnancies occurring annually in 35 countries could have been prevented with the optimal use of MM of contraception. What is known already: Every year, 87 million women worldwide become pregnant unintentionally because of the underuse of MM of contraception. Study design, size, duration: Demographic and health surveys (DHS) of 35 countries, conducted between 2005 and 2012, were analysed. Participants/materials, setting, methods: Contraceptive use of 12 874 unintentionally pregnant women was compared with 111 301 sexually active women who were neither pregnant nor desiring pregnancy. Main results and the role of chance: An average of 96% of 15- to 49-year-old eligible women took part in the survey. When adjusted for covariates and compared with the use of MM of contraception, the use of traditional methods was associated with a 2.7 [95% confidence interval (CI): 2.3-3.4] times increase in odds of an undesired pregnancy, while non-use of any method was associated with a 14.3 (95% CI, 12.3-16.7) times increase. This corresponded to an estimated 16.7 million undesired pregnancies occurring annually in the 35 countries, of which 15.0 million could have been prevented with the optimal use of MM of contraception (13.5 million women did not use MM whilst 1.5 million women utilized MM incorrectly). Women with the lowest educational attainment and wealth quintile were 8.6 (95% CI: 8.2-9.1) and 2.6 (95% CI: 2.4-2.9) times less likely to use contraceptives compared with those with the highest level of each, respectively. Of the 14 893 women who neither desired pregnancy nor used contraception, 5559 (37.3%) cited fear of side effects and health concerns as the reason for non-use, 3331 (22.4%) cited they or their partner\u27s opposition to contraception or religious prohibition and 2620 (17.6%) underestimated the risk of pregnancy. Limitations, reasons for caution: Despite the fact that DHS are considered high-quality studies, we should not underestimate the role played by recall bias for past pregnancies. Few women report a current pregnancy in the first trimester and undesired pregnancies at that time are probably prone to under-reporting. Some terminated pregnancies may not be included in the current pregnancy group. Furthermore, covariates measured at the time of the survey may not have reflected the same covariates at the time the currently pregnant women became pregnant. Wider implications of the findings: Underuse of MM of contraception burdens especially the poor and the less educated. National strategies should address unfounded health concerns, fear of side effects, opposition and underestimated risk of pregnancy, which are major contributors to undesired pregnancies. Funding/conflicts of interest: No external funding was utilized for this report. There are no conflicts of interest to declare

Birth control knowledge among freshmen of four Italian universities

Since sexual health education (SHE) is not mandatory in Italian schools, we conducted a survey on freshmen of four Italian university campuses in 2012 to investigate the respective level of sexual health knowledge (SHK) in relation to birth control, with the aim to inform public health policy makers. A convenience strategy was employed to sample 4,552 freshmen registered with various undergraduate courses at four Italian universities: Padua university (Veneto Region); university of Milan (Lombardy Region); university of Bergamo (Lombardy Region); university of Palermo (Sicily Region). We investigated the level of SHK on birth control using 6 proxy indicators: (1) the average length of a woman\u2019s period [outcome with 3 levels: wrong (base) vs. acceptable vs. correct]; (2) the most fertile interval within a woman\u2019s period (binary outcome: correct vs. wrong answer); (3) the event between the end of a period and the beginning of the next cycle (binary outcome: correct vs. wrong answer); (4) the average survival of spermatozoa in the womb (binary outcome: correct vs. wrong answer); (5) the concept of contraception (binary outcome: correct vs. wrong answer); (6) the efcacy of various contraceptives to prevent unintended pregnancies (linear score: 0\u201317). We ftted 6 separate models of multiple regression: multinomial for outcome 1; logistic for outcomes 2, 3, 4, 6; linear for outcome 6. Statistical estimates were adjusted for a number of socio-demographic factors. Results were expressed as odds ratios (OR) for the 4 multiple logistic regression models, linear coefcients (RC) for the linear regression model and relative risk ratio (RRR) for the multinomial logistic regression model. The level of signifcance of each risk estimate was set at 0.05. The level of SHK of freshmen sampled was rather low, as 60% interviewees did not know the average length of a woman\u2019s period, the average survival of spermatozoa in the womb and the concept of contraception, whilst the most fertile interval within a woman\u2019s period was known only to 55% of interviewees. The mean score of SHK on the efcacy of various contraceptive methods was only 5 (scale 0\u201317). Some categories of students were consistently and signifcantly less knowledgeable on birth control at multivariable analysis: males; students from the university of Palermo; those with vocational secondary school education and those not in a romantic relationship at the time the survey was conducted. The results of this survey clearly call for the introduction of SHE programs in Italian schools, as already done in several European countries. School SHE should start as early as possible, ideally even before secondary school. SHE should be holistic and delivered with a multiple agency coordinated approach involving the Ministry of Health, the Ministry of Education, University and Scientifc Research (MIUR), families, schools, public health departments, primary health care providers, pharmacists, media, other

Effect of Puerperal Infections on Early Neonatal Mortality: A Secondary Analysis of Six Demographic and Health Surveys

Background: Around 1.5 million annual neonatal deaths occur in the first week of life, and infections represent one of the major causes in developing countries. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour. Methods: The association between signs suggestive of puerperal infection and early neonatal mortality (life) was performed using Demographic and Health Surveys (DHS) data of six countries, conducted between 2010 and 2013. The population attributable fraction (PAF) was generated using the estimates on early neonatal mortality of a 1990-2013 systematic analysis for the Global Burden of Disease Study. Results: Signs of puerperal infection ranged from 0.7% in the Philippines to 16.4% in Honduras. Infection was associated with a 2.1 adjusted Risk Ratio (95% CI: 1.4-3.2) of early neonatal mortality. Around five percent of all deaths in the first week of life were attributable to signs suggestive of puerperal infections and varied from 13.9% (95% CI: 1.0-26.6) in Honduras to 3.6% (95% CI: 1.0-8.5) in Indonesia. Conclusions: Targeted interventions should be addressed to contain the burden of puerperal infections on early neonatal mortality. Consideration of the PAF will help in the discussion of the benefits of antenatal and perinatal measures

A Survey on Knowledge, Prevention, and Occurrence of Sexually Transmitted Infections among Freshmen from Four Italian Universities

Background. The peak of sexually transmitted infections (STI) among adolescents/young adults suggests a low level of prevention. In order to assess whether the level of sexual health education (SHE), received by several channels, was effective at improving sexual behaviors, we conducted a survey among freshmen from four Italian universities. Methods. This observational cross-sectional study was carried out with an anonymous self-reported paper questionnaire, administered during teaching lectures to university freshmen of the northern (Padua, Bergamo, and Milan campuses) and southern (Palermo campus) parts of the country. Knowledge of STI (a linear numerical score), knowledge of STI prevention (dichotomous variable: yes vs. no) and previous STI occurrence (polytomous variable: "no"; "don't know"; "yes") were the outcomes in the statistical analysis. Results. The final number of freshmen surveyed was 4552 (97.9% response rate). The mean age of respondents was 21.4 ± 2.2 years and most of them (70.3%) were females. A total of 60% of students were in a stable romantic relationship. Only 28% respondents knew the most effective methods to prevent STI (i.e., condom and sexual abstinence), with a slightly higher prevalence of correct answers among females (31.3%) than males (25.8%). Students with history of STIs were 5.1%; they reported referring mostly to their general practitioner (GP) (38.1%) rather than discussing the problem with their partner (13.1%). At multivariable analysis, a significantly higher level of STI knowledge was observed in older students (25+ years of age), biomedical students, and those from a non-nuclear family; lower levels were found among students of the University of Palermo, and those who completed a vocational secondary school education. Those who had less knowledge about the most effective tools to prevent STIs included males, students from the University of Palermo, students registered with educational sciences, economics/political sciences, those of foreign nationality, and those whose fathers had lower educational levels. The risk of contracting a STI was significantly lower only in students not in a stable relationship (relative risk ratio, RRR = 0.67; 95% confidence interval, 95%CI = 0.48; 0.94), whereas such risk was significantly higher in students with higher STI knowledge (RRR = 1.15; 95%CI = 1.08; 1.22). Discussion and Conclusions. University freshmen investigated in this study had poor knowledge of STIs and their prevention. Unexpectedly, those with higher levels of knowledge had an increased risk of STIs. There have been no educational interventions-with good quality and long-term follow-ups-that increased the confidence that such SHE programs could have population level effects. A new high-quality study is therefore recommended to assess the effectiveness of an intervention generating behavioral changes; increasing only STI knowledge may not be sufficient

Natalizumab affects T-cell phenotype in multiple sclerosis: implications for JCV reactivation

The anti-CD49d monoclonal antibody natalizumab is currently an effective therapy against the relapsing-remitting form of multiple sclerosis (RRMS). Natalizumab therapeutic efficacy is limited by the reactivation of the John Cunningham polyomavirus (JCV) and development of progressive multifocal leukoencephalopathy (PML). To correlate natalizumab-induced phenotypic modifications of peripheral blood T-lymphocytes with JCV reactivation, JCV-specific antibodies (serum), JCV-DNA (blood and urine), CD49d expression and relative abundance of peripheral blood T-lymphocyte subsets were longitudinally assessed in 26 natalizumab-treated RRMS patients. Statistical analyses were performed using GraphPad Prism and R. Natalizumab treatment reduced CD49d expression on memory and effector subsets of peripheral blood T-lymphocytes. Moreover, accumulation of peripheral blood CD8+ memory and effector cells was observed after 12 and 24 months of treatment. CD4+ and CD8+ T-lymphocyte immune-activation was increased after 24 months of treatment. Higher percentages of CD8+ effectors were observed in subjects with detectable JCV-DNA. Natalizumab reduces CD49d expression on CD8+ T-lymphocyte memory and effector subsets, limiting their migration to the central nervous system and determining their accumulation in peripheral blood. Impairment of central nervous system immune surveillance and reactivation of latent JCV, can explain the increased risk of PML development in natalizumab-treated RRMS subjects

Nursing measures to support the needs of haematological cancer survivors post-treatment: a literature review

Background: Patients with haematological cancers are surviving longer due to increasingly effective treatments. Many patients continue to need support and advice after treatment ends. Aims: To review the support needs of patients after treatment for haematological cancer, in order to establish nursing measures for supporting them. Methods: A literature review and thematic analysis of six primary research articles. Findings: Three themes were identified: a sense of abandonment, education about late effects, and becoming a survivor. Conclusion: Understanding an individual's support needs after treatment for haematological cancer enables nurses to offer sensitive, individualised care to patients. A tailored survivorship plan, led by a specialist nurse, helps to meet the ongoing holistic needs of haematological cancer patients

SmartEx: a case study on user profiling and adaptation in exhibition booths

An investigation into user profiling and adaptation with exhibition booth as a case study is reported. First a review of the field of exhibitions and trade fairs and a summary introduction to adaptation and profiling are given. We then introduce three criteria for the evaluation of exhibition booth: effectiveness, efficiency and affect. Effectiveness is related the amount of information collected, efficiency is a measurement of the time taken to collect the information, and affect is the perception of the experience and the mood booth visitors have during and after their visit. We have selected these criteria to assess adaptive and profiled exhibition booths, we call smart exhibition (SmartEx). The assessment is performed with an experiment with three test conditions (non-profiled/non adaptive, profiled/non-adaptive and profiled adaptive presentations). Results of the experiment are presented along discussion. While there is significant improvements of effectiveness and efficiency between the two-first test conditions, the improvement is not significant for the last test condition, for reasons explained. As for the affect, the results show that it has an under-estimated importance in people minds and that it should be addressed more carefully