Heller et al. 1 highlight the potential gap in providing contraception care postpartum. We also saw a missed opportunity to educate postnatal patients about contraception on our wards and to supply such care before discharge. We work in a busy culturally and ethnically diverse area of outer London, with 5300 deliveries annually. We carried out a short face-to-face survey of 50 women who had delivered during the previous week. Twenty-two of the women did not have English as their first language. Their median age was 30 (range 17–43) years, with 36 having a higher education qualification. Average parity following the index pregnancy was two, with 32 women …
Introduction One of the major concerns with the insertion of intrauterine devices is uterine perforation. Though uncommon, it can be debilitating and result in failure of the device. In this article we review uterine perforation with intrauterine contraception (IUC) in a community clinic in the UK over a 16-year period. Methods We prospectively collected data on uterine perforations for the years 2000–2015, reviewed associated factors and calculated the annual rate of perforation, estimating if this lay within the expected range of normal variation using statistical process control (SPC) analysis. We analysed the rates of perforation in relation to the time from delivery and to breastfeeding. Results We identified 30 uterine perforations in 22 795 IUC insertions over the 16 years of observation, with an annual rate ranging from 0 to 4.3 per 1000 insertions, and a mean annual rate of 1.3 per 1000 insertions (95% CI 0.9 to 1.9), which remain within the SPC limits. Twenty-eight of the perforations were in parous women, 87% of whom were within 18 weeks of delivery, peaking at 13 weeks postpartum. Twenty of these were in breastfeeding women. In 3/28 cases for which we have outcome data the device was adherent to or had perforated either the bladder or bowel. Conclusion Our perforation rate is consistent with other studies. Most of our perforations were within 18 weeks of childbirth, earlier than in a recent major study. We cannot tell from our data if there is a true peak in perforations 3 months postpartum as that may be a time when a high proportion of insertions are done.
In this issue, Koh et al. 1 from Singapore report on their randomised study of three vaginal prostaglandin regimens for mid-trimester termination of pregnancy.2 This article addresses gaps in knowledge both of the optimum dose of the most commonly used agent, misoprostol, and of the relative efficacy of the product licensed for this indication, gemeprost. But the question of whether medical termination is, in fact, the most suitable approach for termination after the first trimester remains open to debate. Over the past 20 years, the overall abortion rate in England and Wales, where figures are believed to be compiled with a high degree of accuracy, has plateaued at around 16/1000 women aged 15–44 years. In 2016, over 80% of procedures were undertaken at under 10 weeks’ gestation, with a continuing rise in the proportion utilising early medical abortion.3 However, the proportion of abortions carried out at 13 weeks’ gestation or above has remained static at around 8% and is unlikely to change in the foreseeable future. Mid-trimester abortion will continue to be necessary for a range of reasons including some women’s ambivalence about their decision, women not recognising their pregnancy due to contraceptive use or because they believe that they are infertile due to their age or medical factors, concealed pregnancies (particularly in teenagers), difficulty in engaging services due to mental health problems or learning difficulties, pregnancies that were initially wanted but where the woman’s circumstances have changed, and where serious fetal abnormality has been diagnosed.4 The introduction of more …
Background Although within Latin America Chile has one of the lowest birth rates among adolescents, it has a high rate in comparison to other developed nations. Aim To explore trends in birth rates among adolescents by selected demographics in Chile. Methods The national trend in birth rates was examined for women aged 15–19 years between 1992 and 2012. The birth rates for regions and communes were calculated using birth and census data and were analysed to determine its relationship to the regional or communal poverty rate, which were obtained from the Casen Survey. Differences in educational attainment were explored among adolescents with first-order and second-order or higher births using the Chi-square test. Results The birth rate among adolescents has experienced a 25% decline in the past 20 years. Cross-regional variance in birth rates could not be explained by poverty rates. Within the Metropolitan Region, there is a positive correlation between poverty and adolescent birth rates. Among adolescents giving birth, 67% had completed 10–12 years of school at birth, but there is a significant difference in educational attainment between girls with a first-order and those with a higher-order birth. Conclusions In Chile, the adolescent birth rate varies greatly among regions and communes. This study found that urban and wealthy areas had lower birth rates than poor and rural ones, and that girls with a first-order birth had completed more years of school than girls with higher-order births.
AIM:To evaluate the effects of the etonogestrel contraceptive implant (Implanon®) on bone metabolism in lactating women using markers for bone formation and resorption.STUDY DESIGN:This single-centre, prospective cohort study was conducted in Turgut Ozal University Medical Faculty Obstetrics and Gynecology Department with healthy lactating women aged between 24 and 38 years to compare the effect on bone metabolism of 6 months' use of either the implant or a non-hormonal contraceptive method. The study group (n=25) used an implant and the control group (n=25) used a non-hormonal contraceptive intrauterine device inserted 40 days' postpartum. Bone metabolism differences at the time of insertion and after 6 months were assessed quantitatively by biochemical analysis of serum and urine samples.RESULTS:At baseline, serum levels of bone metabolism parameters were similar for the two groups. In the implant group, serum alkaline phosphatase (ALP) levels decreased (p=0.004) and total protein levels increased (p=0.045) at 6 months. In the control group, serum levels of bone metabolism parameters did not change at 6 months compared to baseline. However, serum levels of phosphorus (p=0.013) and ALP (p=0.003) decreased at 6 months compared to baseline.CONCLUSION:Six months' postpartum use of Implanon was found to have no deleterious impact on bone turnover in healthy lactating women.
Director: Anne Zohra Berrached. Authors (screenplay): Carl Gerber, Anne Zohra Berrached. Germany, 2016. 103 minutes. UK film release: January 2017. UK DVD release: March 2017 “Women's rights are human rights, and human rights are women's rights”, Hillary Clinton told the United Nations Fourth World Conference on Women (Beijing, September 1995). Yet 20 years later she was accused of being a murderer for speaking in favour of legal late-term abortion in her presidential campaign. Her response was nuanced and expressed compassion for women facing the medical realities that drive a late-term abortion. It is a decision that is all too often glossed over or portrayed with tired stereotypes in modern media. The German film, 24 Weeks, innovatively and convincingly shows the difficulties of such a decision: bombardment with advice, data, and opinions from all directions, the rollercoaster of emotions, and the unforeseeable impact on even the happiest couple and family. It avoids simplistic moralism and focuses on the decision at hand. 24 Weeks premiered at the 2016 Berlinale film festival to much critical acclaim and has since won several awards. One of the film's strengths is the exquisite performances. Astrid (Julia Jentsch) and Markus (Bjarne Madel) are a well-off, happy and loving couple and parents of a …
With this journal issue, we are introducing a new requirement for authors of original research papers to tell us how they have involved patients, or service users, in the conception, design, conduction and interpretation of their research. We are doing this because we think it will help us publish better papers – meaning papers better able to improve clinical outcomes - and because we think it is the right thing to do. Involving patients in research is a step towards reducing bias and waste in research1 as well as the kind of injustice which arises when the views of relevant stakeholders are discounted or downgraded.2 We are not the first to take such an initiative – the BMJ has led the way with its Patient Partnership Strategy, …
Sue Lloyd-Roberts. London, UK: Simon & Schuster, 2016. ISBN-13: 978-1-471-15390-7. Price: £16.00. Pages: 320 (hardcover) Not long after the author's death (the journalist, Sue Lloyd-Roberts) in October 2015, I heard her daughter speaking about this book on Radio 4. The ideas behind the book, and its aim to report on the experiences of women worldwide, sounded compelling. However, I was apprehensive that reading the book would prove too disturbing. It is shocking, but also extraordinary, and I could not put it down. Sue Lloyd-Roberts writes transparently, based on the interviews that she conducted. Each chapter begins …
In a letter1 published in the July 2016 issue of this journal, the Breastfeeding Network's approach to postpartum contraception was advocated and described as: (i) avoidance of all hormonal contraception in the first 21 days postpartum; (ii) after that, a month's trial of the “mini-pill” to check milk supply is unaffected; and (iii) initiation of hormonal long-acting reversible contraception (LARC) methods (e.g. the subdermal implant), after this and only if breastfeeding is going well. The letter expresses concern among breastfeeding counsellors, based solely on anecdotal reports, regarding “the impact of hormonal contraception on milk supply” (including progestogen-only methods). The Breastfeeding Network's ‘Breastfeeding and Contraception’ factsheet2 asserts that initiation too early after delivery “may interfere with priming of prolactin receptors” and refers to anecdotal reports …
John Guillebaud. Boca Raton, FL, USA: CRC Press, 2016. ISBN-13: 978-1-498-71460-0. Price: £38.99. Pages: 187 (paperback) This pocket book, while requiring the use of larger pockets over the years, continues to be in a format that is easy to read, engaging and portable. The main text is conversational, and practical points are clearly presented as bullet point lists and with pathways given as flow diagrams, which considerably aid the retention of information. There are also photographs of many …
The inaugural article written by Dr Abi Berger in the new ‘Person in Practice’ series was published in the July 2016 issue of the journal.1 In it, Dr Berger discusses attracting patients with similar conditions to her own. She ‘admits’ to suffering from anxiety and epiretinal membranes in the past and, more recently, to symptoms of menopause including disturbed sleep, night sweats and low mood, which she describes as an abyss. She …
Introduction Unprotected intercourse after oral emergency contraception (EC) significantly increases pregnancy risk. This underlies the importance of promptly starting effective, ongoing contraception – known as ‘quick starting.’ However, theoretical concern exists that quick starting might interact with EC or hormonal contraception (HC) potentially causing adverse side effects. Methods A systematic review was conducted, evaluating quick starting HC after oral EC (levonorgestrel 1.5mg [LNG] or ulipristal acetate 30mg [UPA]). PubMed, EMBASE, The Cochrane Library, ICTRP, ClinicalTrials.gov and relevant reference lists were searched in February 2016. A lack of comparable studies prevented meta-analysis. Results Three randomised controlled trials were identified. Two biomedical studies suggested HC action was unaffected by quick starting after UPA; one study examined ovarian quiescence (OR: 1.27; 95% CI 0.51 to 3.18) while taking combined oral contraception (COC). Another assessed cervical mucus impenetrability (OR: 0.76; 95% CI 0.27 to 2.13) while taking progestogen-only pills (POP). Quick starting POP reduced the ability of UPA to delay ovulation (OR: 0.04; 95% CI 0.01 to 0.37). Side effects (OR: 1.22; 95% CI 0.48 to 3.12) and unscheduled bleeding (OR: 0.53; 95% CI 0.16 to 1.81) were unaffected by quick starting COC after UPA. Another study reported higher self-reported contraceptive use at eight weeks among women quick starting POP after LNG, compared with women given LNG alone (OR: 6.73; 95% CI 2.14 to 21.20). Discussion Limited evidence suggests quick starting HC after UPA does not reduce HC efficacy, however it reduces UPA efficacy. Consequently, women should delay starting HC after UPA.
Ann Furedi. London, UK: Palgrave Macmillan, 2016. ISBN-13: 978-1-137-41118-1. Price: £19.99. Pages: 165 (hardcover) The cover is shabby – like a wrinkled, stained, smudged and mended plain wrapper – signalling the abjection and dirtiness with which abortion has often been associated. But Ann Furedi’s The Moral Case for Abortion is an attempt to rehabilitate abortion, as an idea and a practice, from the ethical, philosophical gutter. It is, in the author’s words, an “assault on the moral high ground.” Going beyond familiar, utilitarian justifications for abortion as an unavoidable fact of life better performed safely than dangerously, Furedi builds a careful and largely convincing moral philosophical arguments for abortion as an actively humanitarian service. Drawing on relevant philosophical and theological argument, alongside medical and cultural ones, she places herself in a “strong, post-enlightenment philosophical tradition”, refusing the “attractive certainties” …
In his editorial in this journal’s April 2017 issue, Grossman anticipated that President Donald Trump would have to make changes from his ambitious electoral promises when making decisions in office.1 Whereas the domestic economy, security and health were top priority issues for the USA presidential election, the themes of a political campaign are quite different from the precise positions required during policy formulation, especially when world events intrude on the “America first” transactional perspectives that seek to “make America great again”. With both health and security knowing no geographical boundaries, a domestic agenda has global repercussions. Reacting to the anticipated international “population bomb” of the 1960s, the USA promoted family planning (FP), which was subsequently recognised as an integral part of maternal and child health, an essential element of primary healthcare as defined by the World Health Organization (WHO) in 1978. Considering …
The use of ethyl chloride to anaesthetise the skin by cooling before implant insertion has been used and documented previously.1 I was trained to remove deep implants by the very experienced Dr Martyn Walling, but have observed over the last few months that some of the deep fittings have included the use of ethyl chloride as anaesthetic prior to insertion. Dr Walling taught me that once the bevel …
Emily Nagoski. London, UK: Scribe Publications, 2015. ISBN-13: 978-1-925-22801-4. Price: £12.99. Pages: 432 (paperback) There are now literally thousands of books – my own among them – which aim to help women understand and make the most of their sexuality. This book, however, is special. Written by Emily Nagoski, formerly Director of Wellness Education at Smith College (Massachusetts, USA) and the Kinsey Institute (Indiana, USA), the book rises above most others for many reasons. The first is its range: the 400+ pages cover not only female physiology, sexual response, and ‘what to do in bed’, but also the emotional and relational underpinnings of sexuality; its social context; its pitfalls, its pleasures. A full set by any count and, as the book's cover claims, …
I was very interested to read Speedie et al .'s report1 on their carefully conducted randomised trial of two stabilising forceps for the insertion of intrauterine contraception (IUC). Their finding that there is no significant difference in the pain experienced on application of single-toothed volsellum forceps and Littlewood forceps in the specific group of women selected, those with at least one vaginal delivery, is interesting, and was certainly worth establishing objectively. However, I was disappointed that the instrument selected by them as the comparator for the obviously ‘traumatic’ single-toothed volsellum was the Littlewood forceps rather than a commonly-used alternative, the Judd-Allis forceps. The Judd-Allis forceps (Figure 1A) is a lengthened form of the Allis forceps that …
There has long been uncertainty as to how the continued use of the contraceptive injection depot medroxyprogesterone acetate (DMPA) affects bone mineral density (BMD). DMPA inhibits ovulation.1 Hence women on long-term DMPA may have relatively low estradiol levels, and some experience estrogen deficiency symptoms. Estrogen is integral to bone health.2 However, low serum levels of estradiol are not reliable indicators of BMD.3 A systematic review by the National Institute of Health and Care Excellence4 concluded that DMPA use is associated with a small loss of BMD, but it appears that this recovers to normal or near normal when DMPA is discontinued. At present clinicians are advised to use DMPA judiciously. A risk–benefit equation should be undertaken for every patient to help them choose the most appropriate method of contraception. For women who are at risk of osteopenia or osteoporosis, methods other than DMPA may be preferable. Two particular groups of patients represent higher risk groups for poor bone health and DMPA. The first are young teenagers who have not yet achieved their peak bone mass, and the second are older women (aged over 40–45 years) who have been using DMPA and who are now approaching menopause. The 2014 Faculty of Sexual & Reproductive Healthcare (FSRH) guidance on the use of progestogen-only injectable contraception states that DMPA can be used in young …
We wish to share with journal readers a clinical case that challenged us clinically and highlighted a number of learning points for our community sexual and reproductive healthcare (cSRH) service. A transgender male attended our integrated sexual health clinic with a presentation of blisters. He had had unprotected vaginal sexual intercourse 5 days previously, and had been paid for this episode of sex. He was in a long-term relationship with his female partner, and was considering going into casual sex work (CSW). Currently he was a full-time carer for his partner, while also trying to hold down a part-time cleaning job. His transgender friends had informed …
We thank Quispe Calla and colleagues for their insightful comments1 on our article.2 We agree that basic science evidence showing that various progestogens increase HIV susceptibility is compelling. We also agree that randomised clinical trials (RCTs) are informative regarding the relative risks of HIV between contraceptive alternatives, but not the absolute risks …
