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There is clinically important comorbidity between psychiatric and substance use disorders, particularly in women. Women with affective and anxiety disorders are more likely to present with alcohol or drug abuse/dependence. In turn, substance-abusing women are more likely to experience clinically significant depression and anxiety. Emerging evidence is pointing to an etiological role for anxiety disorders in the development of substance abuse/dependence; however, etiologic evidence is not as clear-cut for major depressive disorder. PTSD appears to be a particularly important factor for alcohol and drug dependence in women who have experienced childhood or adult sexual and or physical abuse. Although pharmacotherapy for affective or anxiety disorders is useful for ameliorating psychiatric symptoms, research is mixed on the effectiveness for improving alcohol- and drug-related outcomes. There is some limited evidence that women-specific services can improve treatment retention, substance use outcomes, and possibly psychosocial functioning compared with traditional mixed-gender programs. However, it is clear that women with co-occurring psychiatric and substance use problems are challenging to engage and retain in care. Physicians providing women's reproductive health services can serve a vital role in the identification and referral of substance-abusing women. Particular attention should be focused on screening and assessment of alcohol and drug use and problem severity among women who have identified psychiatric disorders or who are receiving antidepressant or anxiolytic medications. Recognition and referral for both psychiatric and substance use disorders are critical for long-term health and psychosocial improvement.
Community-based reproductive health services (CBRHS) have been in implementation in Ethiopia for over a decade. This paper assesses the impact of such programmes on contraceptive use. The data were obtained from the 2000 Ethiopian Demographic and Health Survey (DHS) and the 2003 Contraceptive Prevalence Survey (CPS). While the 2000 DHS contained a nationally representative random sample of women of reproductive age, the 2003 CPS focused on areas with active CBRHS programmes. The findings indicate that expanding the current CBRHS programme has the potential of doubling the current national contraceptive prevalence rate.
Since the mid-1990s, several provincial bills have been passed in Argentina mandating the creation of programmes for family planning and sexual health services and education. A National Plan for Integrated Health Care for Adolescents was also passed but resources and actual programmes remain limited. The policy process has been fraught with difficulties, owing to a strong alliance between the State and the Catholic church. Provision of contraceptives to adolescents has been one of the most contentious issues, as adolescents are legally minors and need parental permission to use family planning. NGOs are working with young people to help them to voice their perspectives and demands. The Programme for Responsible Sexuality was launched by the Province of Buenos Aires in 1999, in response to concrete demands on the part of poor communities for sexual and reproductive health services, including for young people. This Programme came to an abrupt end with the change of governor in that same year, illustrating the complexity of the policy-making process. These experiences demonstrate the urgency to develop strategies and set up task forces for effective advocacy of health and social programmes, and to make political leaders more aware of the social costs of refusing to support these.
This report describes a mid-course process evaluation of an HIV risk-reduction counseling intervention delivered by specially trained peer paraprofessionals. One of the key questions addressed is whether paraprofessionals can successfully implement a theory-based counseling intervention. The project, known as Project CARES, is a 5-year demonstration research project to prevent HIV infection and unplanned pregnancies in women at risk for HIV infection and transmission who were recruited from homeless shelters, drug treatment facilities, and hospital-based service settings for HIV-infected women. Project CARES uses an enhanced counseling intervention based on the Transtheoretical Model, also known as the Stages of Change model, to promote condom and other contraceptive use for women who wish to avoid pregnancy, condom use for disease prevention, and reproductive health service use. Peer paraprofessionals, called advocates, provide stage-tailored counseling using a structured manual which guides them in the selection of specific counseling activities appropriate to a woman's level of readiness to change her behavior. Data from process evaluation forms completed by advocates in Philadelphia and Baltimore document that the delivery of the intervention is consistent with the theoretical model upon which it was based. Paraprofessionals can become skilled in the delivery of a stage-based counseling intervention in health and social service settings. The use of paraprofessionals in HIV prevention service delivery may be a cost-effective way to enhance and extend services for women.
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OBJECTIVE: To describe and evaluate the training and support provided to the first cohort of community pharmacists to supply progestogen-only emergency contraception (POEC) under a Patient Group Direction (PGD) in Lambeth, Southwark and Lewisham, London. DESIGN: The study comprised (a) a systematic analysis of written and oral data from pharmacists before and during training, and at 5 and 13-14 months after launch; (b) analysis of telephone calls to clinical support and (c) analysis of written pharmacy records. SUBJECTS: A total of 20/22 pharmacists in the first training cohort; 6/23 pharmacists who applied but were not accepted were also followed up. RESULTS: A formal course with role-play was a successful training method, and the course also served as a team-building exercise. Subsequent interviews demonstrated that pharmacists had understood the concept of client confidentiality and gained confidence over time in the use of the PGD. The on-call consultants received 152 calls in the first 12 months of the scheme. Over 80% of the calls concerned clinical criteria (notably including 22% that were queries about oral contraceptives). Frequency ranged from one to eight calls per week with 28% made at weekends. In over half (60%) of the calls the pharmacist was subsequently able to make a supply. Queries over client management resulted in several changes in the protocol. The primary expressed concern for all pharmacists at all time points was how clients might 'misuse' or 'abuse' the service, and this remained a concern despite the fact that it also applies to other routes of supply of POEC. However, the PGD cohort was more positive on local benefits than pharmacists who were not selected. CONCLUSIONS: Training and support have enabled this often-underused group of professionals to participate in an extended reproductive health service. Mobile phones are an essential support tool.
Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the world's poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.
Some health indicators for Latinos tend to be more positive than socioeconomic status would predict. Yet, Latina women and their young children use fewer preventive health services and have a higher incidence of preventable diseases than non-Hispanic whites. The Institute of Medicine recently called for intervention research among minority subgroups to end racial and ethnic disparities in health care. To help guide future intervention research, this article presents a critique and synthesis of the peer-reviewed literature on interventions that enroll Latina women into preventive reproductive health services (prenatal care, cervical cancer screening, and child immunizations). Results are presented according to three categories of interventions: improvements within formal health care settings, outreach through lay health advisors (promotoras) and media, and interventions combining these approaches. An agenda for intervention research is proposed for preventive-care use by this population.
This article examines the cases for and against commercializing, or "commodifying," reproductive materials and services. Using a supply/demand third-party framework, three basic scenarios in which commercial-exchange relationships may be possible--exchange of gametes and zygotes, exchange of gestational services, and exchange of fetal material--and the major parties of interest, or stakeholders, are identified. The study sketches the liberal, essentialist, and radical contingency theories that shape the debate over the commercialization of reproductive materials and services. The article then attempts to derive some basic governing principles that reflect as much common ground as possible amongst these various normative perspectives, while recognizing that complete reconciliation is impossible. Taken together, these principles are designed to reflect a strategy of "constrained commodification," where commercialization or commodification, that is, financial remuneration, plays a relatively neutral role in the utilization of reproductive materials and services. In light of these principles, the article concludes by sketching legal and regulatory regimes with respect to the exchange of gametes and zygotes, gestational services, and fetal tissue.
In Mexico, people utilize public, private and traditional health providers interchangeably and in contrast to official access policies. Access policies for prenatal and child delivery services are evaluated using data from the National Health Survey of 1988. The study documents significant coverage gaps on the part of public providers with respect to their potential coverage, and especially, large cross-utilization of social security, Ministry of Health and private providers by beneficiaries. Child deliveries in Mexico are attended by a physician in only 66% of cases. The percentages are 85% for social security affiliates, 53% for women within reach of IMSS-Solidarity services (a relief programme for the rural poor) and only 31% for women with official access to private or Ministry of Health care, or beyond the reach of services. Seventy-eight per cent of medical deliveries by women affiliated to social security occur at their pre-paid facilities, while 14% deliver at extra cost with private physicians, contributing to 32% of deliveries so offered. Even though only 7% of insured women deliver at Ministry of Health facilities, this amounts to 20% of the Ministry's relief offer. In all, only 66% of affiliates use social security delivery services. On the other hand, 36% of deliveries by non-insured women are cared for by Ministry of Health providers, and 39% by the private sector; 22% of such deliveries occur in social security institutions, amounting to 18% of these institutions' care offer. These results indicate a wide departure between policy and fact, and the working of distributive and redistributive forces that impinge on the quality and efficiency of health care. Open access to the reproductive health services of all public institutions, with coordination among them and private providers, is suggested as a possible solution.
This study was undertaken to determine the proportion of family planning organization clients who are from a non-English speaking background (NESB), to analyse the services they used, and to compare it to the services used by other clients. Analysis of clinic data sheets from the 8 State/Territory family planning organizations (FPO) was conducted. From a total of 185,879 client visits in FPO clinics between July, 1996 and June, 1997, 27,349 (14.7%) were from NESB. The proportion of clients with NESB was quite similar to that in the community. This means that in general, FPOs are reaching their share of clients with NESB. The patterns of reproductive health services used varied between NESB women compared to English speaking women.
School-based clinics in St. Paul have provided comprehensive health services, including reproductive health care, for almost two decades. This study examines the effects of those clinics on the birthrates in their respective schools, using a newly developed methodology with numerous advantages over previous methods for estimating student birthrates. Confidentially matching the names of female students from school records with the names of mothers on birth records at the Department of Health provided birthrates for each of the St. Paul public high schools with clinics for each year between 1971 and 1986. The results show that birthrates fluctuated dramatically from one year to the next, but school-wide birthrates were not significantly lower in the years immediately following the opening of a clinic than in the years preceding it.
Nephrologists are often responsible for the primary care of their female patients with chronic renal disease. As such, they must be cognizant of medical issues that are unique to women. Awareness and implementation of routine health care maintenance and cancer screening recommendations are essential. The provision of reproductive health services, which includes menstrual history assessment, contraception counseling, and services relating to child bearing and sexual functioning, is also necessary. Menopausal health concerns and hormone replacement therapy are frequently overlooked and need to be addressed. In general, the primary care of women with chronic renal disease is similar to that of women without renal disease and should adhere to current standards of preventive care.
Counselling was made a statutory requirement for clinics providing assisted reproduction services as a result of the concern raised that these treatments would raise uniquely challenging emotional and ethical problems for patients. Before the Human Fertilisation and Embryology Act 1990, few counsellors specialized in this field and there were no standards for their training or experience. In the intervening years considerable progress has been made in these areas. The research evidence, which informs their practice concerning the impact of infertility and its treatment, has also grown very substantially. There is now a reasonable consensus about the broad nature of the emotional and psychological sequelae, although many unexplored questions remain. In addition, the literature providing evidence for the efficacy and effectiveness of counselling in other areas has developed in both quantity and sophistication. Counsellors are often well-placed to work with patient groups and also with the multidisciplinary assisted conception team itself on the very difficult psychosocial and ethical issues faced in practice. The sophisticated research in these fields has not yet been done in the context of infertility; it is therefore necessary to extrapolate from other fields, especially in mental health practice. This article will argue that there is now ample evidence to support the decisions made by legislators in requiring counselling to be available to patients in assisted conception units. The infertility counselling profession is in a position to begin contributing to the generation of research relevant to this field.
BACKGROUND: Clinical symptomatology and socio-demographic factors have not been characterized in Jamaican adolescents with HIV/AIDS. METHODS: We studied these factors in 25 HIV-positive Jamaican adolescents, 10-19 years of age, who were seen at the Centre for HIV/AIDS Research, Education, and Services (CHARES) between the years 1996 and 2002. Data were collected between June 2003 and August 2003 from CHARES social work files and The University Hospital of the West Indies (UHWI) medical records. Microsoft Excel was used to compile descriptive statistics for the data. RESULTS: The mean age of HIV diagnosis was 15.6 (+/-3.09) years, and the mean age of enrollment at CHARES was 16.3 (+/- 2.9) years. Consensual sexual intercourse was the most prominent mode of transmission (56%), followed by vertical transmission (16%), unknown (16%), forced sexual intercourse (8%), and blood transfusion (4%). The predominant clinical presentations among these adolescent patients were generalized dermatitis (77.2%) and lymphadenopathy (50%). Of the patients for whom clinical status could be determined, 70% were "Severely Symptomatic ". Of these patients only 14% were recommended for antiretroviral treatment. CONCLUSIONS: These findings reinforce the need to globally incorporate the goal of the 2002 Joint United Nations Programme on HIV/AIDS (UNAIDS) "to provide reproductive health services, including low-cost or free condoms, voluntary counselling and testing, diagnosis and treatment of sexually transmitted diseases and infections for adolescents in order to effectively prevent HIV infection " (1).
This article presents findings from a survey conducted in Kenya in 1985 of the reproductive health knowledge, attitudes, and practices among more than 3,000 unmarried Kenyan youth, students and nonstudents, between the ages of 12 and 19. The survey was designed to elicit information that would be useful in gauging the kinds of problems Kenyan adolescents face in order to design programs that meet their needs. The study shows that although a solid majority of adolescents appear to have received information on reproductive health, the quality of the information is generally low. Fewer than 8 percent could correctly identify the fertile period in a woman's menstrual cycle. A substantial proportion of the population surveyed, more than 50 percent, is sexually active, having initiated intercourse some time between 13 and 14 years of age, on average. In spite of a general disapproval of premarital sex (but approval of the use of contraceptives among the sexually active), most of the sexually active population--89 percent--have never used contraceptives. The many contradictions between attitudes and practices pose serious questions and demonstrate the need to reexamine the programs (and policies) that provide access to reproductive health services to adolescents in Kenya.
Experience is reported with 28 uterine perforations encountered from June 1, 1973, to June 1, 1976, among 20,000 first trimester abortion patients at Reproductive Health Services, St. Louis, Missouri. In order to prevent this complication, one must perform an exacting pelvic examination. The use of a sound is controversial. Dilators should be introduced only a short distance through the internal os, and as much of the products of conception as possible should be aspirated. A sharp curette should be diagnostically. Various questions should be asked before the operator constructs a scheme for managing perforation. The current policy for management used at this clinic is outlined.