Using quantitative ultrasound for epidemiological research : associations with risk factors for low bone mineral density in South African premenopausal women

Includes bibliographical references (leaves 57-63).Quantitative Ultrasound (QUS) measurement at the calcaneum is a convenient, cost effective and noninvasive method of determining bone strength well suited to community-based research in countries with limited resources. Although only moderately correlated with dual X-ray absorptiometry (DEXA) measurement of bone mineral density (BMD) at the hip and spine, quantitative ultrasound has shown to be a reliable predictor of osteoporotic fracture. This study aims to evaluate the use of QUS in epidemiological studies in South African settings. To this end, this report determines whether characteristics associated with QUS measures of bone strength in a large sample of premenopausal South African women are similar to those known to be associated with the BMD as measured by DEXA, and compares these associations with those in other populations. This cross-sectional study included 3493 black and mixed race women aged 18 - 44 living in Cape Town. Trained study nurses administered structured interviews on reproductive history and lifestyle factors. In addition they took height, weight and calcaneal QUS measurements using the Sahara device. Adjusted means of QUS measures according to categories of risk factors were obtained using multivariable regression analysis. In both groups associations between QUS measures and age, Body Mass Index (BMI), age at menarche, parity and primary school physical activity were similar to those known to be associated with BMD as measured by DEXA. There were no clear associations between QUS and educational level, alcohol use, cigarette smoking, and current calcium intake. The data give support to the use of QUS as an epidemiological tool in large studies of bone strength in premenopausal women

Strengthening medical abortion in South Africa

Access to safe, legal abortion services is an important public health measure to address morbidity and mortality from unsafe abortion. To expand access and strengthen medical abortion provision in South Africa, evidence is needed on the safety, effectiveness, feasibility and acceptability of task sharing strategies and the implementation of evidence-based regimens. This research aims to: (a) evaluate the safety and acceptability of task sharing gestational age estimation for women seeking abortion, (b) determine the effectiveness and acceptability of text messaging on mobile phones to support women self-managing medical abortion, (c) evaluate the feasibility, safety and acceptability of self-assessment of medical abortion completion using mobile phones alone or in combination with a low-sensitivity pregnancy test, and (d) document clinical outcomes and women's experiences following the introduction of mifepristone into second trimester medical abortion services. Published or submitted papers included in this thesis are from four prospective studies evaluating interventions and interviewing women and health care workers in South African public sector and non-governmental clinics between 2011 and 2015. The first paper establishes that last menstrual period is sufficiently accurate to estimate gestational age in selected women (97%) and has potential to be task shared with community health workers or women themselves. The second paper reports reduced anxiety (p=0.013) and better preparedness (p=0.016) for self-managing abortion symptoms among women receiving automated text messages (compared to those receiving standard care). The third and fourth papers show that mobile phones are a feasible modality for self-assessment for most women (86%), but that clinical history needs to be combined with an appropriate pregnancy test to detect incomplete or failed procedures. Self-assessment using a low-sensitivity pregnancy test is preferred by most women (98%) to in-clinic follow-up, and providing a guided demonstration on the use of a low-sensitivity pregnancy test does not significantly impact on the accuracy of self-assessed abortion outcome compared to simple verbal instructions (88% vs. 85% accuracy; p=0.449). The fifth paper documents successful self-administration of mifepristone, a higher 24-hour abortion rate (93% vs 77%; p<0.001), and greater acceptability following the introduction of mifepristone into second trimester abortion care, compared to historic cohorts receiving misoprostol only. The thesis concludes that supported self-management and task sharing can strengthen medical abortion provision in South Africa. Research evaluating task sharing of medical abortion care has potential to inform similar approaches for other health care services

Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study

BACKGROUND: The requirement for ultrasound to establish gestational age among women seeking abortion can be a barrier to access. Last menstrual period dating without clinical examination should be a reasonable alternative among selected women, and if reliable, can be task-shared with non-clinicians. This study determines the accuracy of gestational age estimation using last menstrual period (LMP) assessed by community health care workers (CHWs), and explores providers' and CHWs' perspectives on task sharing this activity. The study purpose is to expand access to early medical abortion services. METHODS: We conducted a multi-center cross-sectional study at four urban non-governmental reproductive health clinics in South Africa. CHWs interviewed women seeking abortion, recorded their LMP and gestational age from a pregnancy wheel if within 63 days. Thereafter, providers performed a standard examination including ultrasound to determine gestational age. Lastly, investigators calculated gestational age for all LMP dates recorded by CHWs. We compared mean gestational age from LMP dates to mean gestational age by ultrasound using t-tests and calculated proportions for those incorrectly assessed as eligible for medical abortion from LMP. In addition, in-depth interviews were conducted with six providers and seven CHWs. RESULTS: Mean gestational age was 5 days (by pregnancy wheel) and 9 days (by LMP calculation) less than ultrasound gestational age. Twelve percent of women were eligible for medical abortion by LMP calculation but ineligible by ultrasound. Uncertainty of LMP date was associated with incorrect assessment of gestational age eligibility for medical abortion (p = 0.015). For women certain their LMP date was within 56 days, 3% had ultrasound gestational ages >70 days. In general, providers and CHWs were in favour of task sharing screening and referral for abortion, but were doubtful that women reported accurate LMP dates. Different perspectives emerged on how to implement task sharing gestational age eligibility for medical abortion. CONCLUSIONS: If LMP recall is within 56 days, most women will be eligible for early medical abortion and LMP can substitute for ultrasound dating. Task sharing gestational age estimation is feasible in South Africa, but its implementation should meet women's privacy needs and address healthcare workers' concerns on managing any procedural risk

Is 'planning' missing from our family planning services?

The role of family planning in achieving the Millennium Development Goals is well recognised. The benefits of family planning, in developing countries in particular, extend beyond decreasing fertility and include poverty reduction, improved health for both mother and child, the promotion of gender equality by increasing women's opportunities beyond reproductive and domestic activities, and environmental sustainability. In addition, prevention of undesired pregnancies among HIV-positive women by eliminating unmet need for contraception is a highly cost-effective means of preventing mother-to-child transmission. In South Africa, free contraceptives are available at public sector health care facilities, and contraception use is high: an estimated 65% of sexually active women use a method.3 The method mix comprises predominantly short-acting methods - primarily injectable contraceptives. Long-acting contraceptives, such as the intra-uterine device (IUD), are highly effective among typical users owing to consistency of function, yet are underutilised in South Africa's public sector facilities. Of importance, especially in South Africa's high HIVprevalent setting, is that the IUD can be safely used on clinically well HIV-positive women. The 2004 Demographic and Health Survey showed that 10% of sexually active women were sterilised, while less than 1% of women were using the IUD. In preparation for an intervention aimed at improving contraceptive options, including long-acting and permanent methods (LAPM), for all postpartum women, we assessed women's knowledge and attitudes to LAPM. We report on findings from our baseline survey, which have prompted the question: Where is the 'planning' in family planning services

Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa.</p> <p>Methods</p> <p>A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined.</p> <p>Results</p> <p>The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods.</p> <p>Conclusions</p> <p>Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.</p

Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa

Background: South Africa has a liberal abortion law, yet denial of care is not uncommon, usually due to a woman being beyond the legal gestational age limit for abortion care at that facility. For women successfully obtaining care, time from last menstrual period to confrmation of pregnancy is signifcantly longer among those having an abortion later in the second trimester compared to earlier gestations. This study explores women’s experiences with recognition and confrmation of unintended pregnancy, their understanding of fertile periods within the menstrual cycle as well as healthcare providers’ and policy makers’ ideas for public sector strategies to facilitate prompt confrmation of pregnancy. Methods: We recruited participants from July through September 2017, at an urban non-governmental organization (NGO) sexual and reproductive health (SRH) facility and two public sector hospitals, all providing abortion care into the second trimester. We conducted in-depth interviews and group discussions with 40 women to elicit information regarding pregnancy recognition and confrmation as well as fertility awareness. In addition, 5 providers at these same facilities and 2 provincial policy makers were interviewed. Data were analysed using thematic analysis. Results: Uncertainties regarding pregnancy signs and symptoms greatly impacted on recognition of pregnancy status. Women often mentioned that others, including family, friends, partners or colleagues noticed pregnancy signs and prompted them to take action. Several women were unaware of the fertility window and earliest timing for accurate pregnancy testing. Health care providers and policy makers called for strategies to raise awareness regarding risk and signs of pregnancy and for pregnancy tests to be made more readily accessible. Conclusion: Early recognition of unintended pregnancy in this setting is frustrated by poor understanding and awareness of fertility and pregnancy signs and symptoms, compounded by a distrust of commercially available pregnancy tests. Improving community awareness around risk and early signs of pregnancy and having free tests readily available may help women confrm their pregnancy status promptly

Clinical outcomes and women's experiences before and after the introduction of mifepristone into second-trimester medical abortion services in South Africa

Objective To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. METHODS: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort. RESULTS: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. CONCLUSION: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed

From symptom discovery to treatment - women's pathways to breast cancer care: a cross-sectional study

Background Typically, women in South Africa (SA) are diagnosed with breast cancer when they self-present with symptoms to health facilities. The aim of this study was to determine the pathway that women follow to breast cancer care and factors associated with this journey. Methods A cross-sectional study was conducted at a tertiary hospital in the Western Cape Province, SA, between May 2015 and May 2016. Newly diagnosed breast cancer patients were interviewed to determine their socio-demographic profile; knowledge of risk factors, signs and symptoms; appraisal of breast changes; clinical profile and; key time events in the journey to care. The Model of Pathways to Treatment Framework underpinned the analysis. The total time (TT) between a woman noticing the first breast change and the date of scheduled treatment was divided into 3 intervals: the patient interval (PI); the diagnostic interval (DI) and the pre-treatment interval (PTI). For the PI, DI and PTI a bivariate comparison of median time intervals by various characteristics was conducted using Wilcoxon rank-sum and Kruskal-Wallis tests. Cox Proportional-Hazards models were used to identify factors independently associated with the PI, DI and PTI. Results The median age of the 201 participants was 54 years, and 22% presented with late stage disease. The median TT was 110 days, with median patient, diagnostic and pre-treatment intervals of 23, 28 and 37 days respectively. Factors associated with the PI were: older age (Hazard ratio (HR) 0.59, 95% CI 0.40–0.86), initial symptom denial (HR 0.43, 95% CI 0.19–0.97) and waiting for a lump to increase in size before seeking care (HR 0.51, 95% CI 0.33–0.77). Women with co-morbidities had a significantly longer DI (HR 0.67, 95% CI 0.47–0.96) as did women who mentioned denial of initial breast symptoms (HR 4.61, 95% CI 1.80–11.78). The PTI was associated with late stage disease at presentation (HR 1.78, 95% CI 1.15–2.76). Conclusion The Model of Pathways to Treatment provides a useful framework to explore patient’s journeys to care and identified opportunities for targeted interventions