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Lancet. Oncology. 2018 Dec; 19(12):e657.Add to my documents.
Lancet. Oncology. 2018 Dec; 19(12):e658.Add to my documents.
Rockville, Maryland, ICF, 2018 Sep. 51 p. (DHS Methodological Reports No. 23; USAID Project No. AID-OAA-C-13-00095)Early childbearing carries serious risks to the health of both the child and the mother. International guidelines classify births before age 18 as high-risk births, and births before age 15 are of even greater concern. Early marriage and pregnancy are also interpreted as negative indicators of child protection, and may severely limit an adolescent girl’s educational opportunities. DHS surveys are a major source of fertility estimates for age 15-49, the age range of eligibility for the women’s interview and the collection of birth histories. Until recently, DHS surveys were not used for the calculation of fertility rates below age 15. This methodological report provides technical details for calculating fertility rates for age 12-14 and age 10-14 during the 3 years before the survey, and age 10-14 during the 5 years before the survey, the standard time intervals for DHS age-specific fertility rates. The under-15 births, which go into the numerator of the fertility rates, are obtained from the birth histories of women age 15-19 at the time of the survey. The central question is how to deal with the left censoring of under-15 exposure, which goes into the denominator of fertility rates, but is truncated because girls under age 15 are not included in the surveys. To deal with censoring, rates for single years of age 10, 11, 12, 13, and 14 are constructed. DHS does not normally construct single-year rates, but they are of special interest below age 15 and convenient for calculating 3-year and 5-year rates. Single-year rates are only slightly affected by censoring. For example, the mean age observed for age 14 in the past 3 years is only about 12 days higher than 14.5. Pooled rates for age 12-14 or 10-14 are constructed as weighted averages of the single-year rates. Three alternative weighting methods are considered. The first uses information about girls age 10-14, who are included in the household survey but not in the women’s survey. The second uses weights derived from the geometry of a Lexis diagram. These estimates are easier to calculate and are the ones currently available on STATcompiler. The third method is simply the arithmetic average of the single-year rates. These estimates are the easiest to calculate but lack a demographic rationale. The second and third methods, when relevant, also assume that 60% of the total exposure to age 10-14 is to age 12-14. This report applies the alternative approaches to 67 DHS surveys conducted between 2001 and 2016. The three estimates are virtually indistinguishable in almost all surveys. When they differ, the main reasons appear to be that the assumption of 60% is not valid and/or there are irregularities in the reported age distribution that are probably traceable to digit preference or age displacement across the age 15 boundary or potential age displacement related to having an early birth. The first method, which makes the most use of the available data, is most sensitive to data quality. The third method, which makes the least use of available data, is least sensitive to data quality. The report describes simulations of the effect of reducing the minimum age for eligibility from 15 to 14, or to 13, in terms of the expected additional number of under-15 births and the expected improvement in the precision of the estimated rate. The gain from lowering the age range of eligibility below age 15 would be surprisingly small. Most under-15 fertility occurs at age 14, and the birth histories of women 15-19 provide nearly complete information on births at age 14.
Lancet. Infectious Diseases. 2017 Aug; 17(8):804.Add to my documents.
Genus. 2018; 74(10): p.Adult mortality is an important development and public health issue that continues to attract the attention of demographers and public health researchers. Controversies exist about the accurate level of adult mortality in sub-Saharan Africa (SSA), due to different data sources and errors in data collection. To address this shortcoming, methods have been developed to accurately estimate levels of adult mortality. Using three different methods (orphanhood, widowhood, and siblinghood) of indirect estimation and the direct siblinghood method of adult mortality, we examined the levels of adult mortality in 10 countries in SSA using 2001–2009 census and survey data. Results from the different methods vary. Estimates from the orphanhood data show that adult mortality rates for males are in decline in South Africa and West African countries, whilst there is an increase in adult mortality in the East African countries, for the period examined. The widowhood estimates were the lowest and reveal a marked increase in female adult mortality rates compared to male. A notable difference was observed in adult mortality estimates derived from the direct and indirect siblinghood methods. The method of estimation, therefore, matters in establishing the level of adult mortality in SSA.
International Journal of Gynaecology and Obstetrics. 2015 Jul; 130(1):98-110.BACKGROUND: Maternal and neonatal mortality remains a serious challenge in Tanzania. Progress is tracked through maternal mortality ratios (MMR) and neonatal mortality rates (NMR), yet robust national data on these outcomes is difficult and expensive to ascertain, and mask wide variation. SEARCH STRATEGY: We searched EMBASE, MEDLINE, Popline, and EBSCO online databases, basing search terms on ("maternal" OR "neonatal") AND ("mortality" OR "cause of death") AND "Tanzania." SELECTION CRITERIA: Nationally representative or population representative from the subnational context were eligible, providing NMR, MMR, or numbers of maternal deaths or early neonatal deaths or neonatal deaths and live births. DATA COLLECTION AND ANALYSIS: Data were extracted on study context, time period, number of deaths and live births, definition of maternal and neonatal death, study design, and completeness and representativeness of data. NMR and MMR were extracted or calculated and study quality was assessed. Nationally representative data were compared with modelled national data from international agencies. MAIN RESULTS: 2107 records were screened yielding 21 maternal mortality and 15 neonatal mortality datasets. There were high mortality levels with wide subnational MMR and NMR variation. National survey data differed from the modelled estimates, with wide uncertainty ranges. CONCLUSION: Subnational data quality was generally poor with no observable trends and geographical clustering across several regions. Combined MMR and NMR reporting is uncommon. Modelled national estimates lack precision and are complex to interpret. Results suggest that aggregate national data are inadequate for policy generation and progress monitoring. We recommend strengthening of vital registration and Health Management Information Systems with complementary use of process indicators, for improved monitoring of, and accountability for maternal and newborn health. Copyright (c) 2015. Published by Elsevier Ireland Ltd.
List randomization for eliciting HIV status and sexual behaviors in rural KwaZulu-Natal, South Africa: A randomized experiment using known true values for validation.
BMC Medical Research Methodology. 2018; 18(1)Background: List randomization (LR), a survey method intended to mitigate biases related to sensitive true/false questions, has received recent attention from researchers. However, tests of its validity are limited, with no study comparing LR-elicited results with individually known truths. We conducted a test of LR for HIV-related responses in a high HIV prevalence setting in KwaZulu-Natal. By using researcher-known HIV serostatus and HIV test refusal data, we were able to assess how LR and direct questionnaires perform against individual known truth. Methods: Participants were recruited from the participation list from the 2016 round of the Africa Health Research Institute demographic surveillance system, oversampling individuals who were HIV positive. Participants were randomized to two study arms. In Arm A, participants were presented five true/false statements, one of which was the sensitive item, the others non-sensitive. Participants were then asked how many of the five statements they believed were true. In Arm B, participants were asked about each statement individually. LR estimates used data from both arms, while direct estimates were generated from Arm B alone. We compared elicited responses to HIV testing and serostatus data collected through the demographic surveillance system. Results: We enrolled 483 participants, 262 (54%) were randomly assigned to Arm A, and 221 (46%) to Arm B. LR estimated 56% (95% CI: 40 to 72%) of the population to be HIV-negative, compared to 47% (95% CI: 39 to 54%) using direct estimates; the population-estimate of the true value was 32% (95% CI: 28 to 36%). LR estimates yielded HIV test refusal percentages of 55% (95% CI: 37 to 73%) compared to 13% (95% CI: 8 to 17%) by direct estimation, and 15% (95% CI: 12 to 18%) based on observed past behavior. Conclusions: In this context, LR performed poorly when compared to known truth, and did not improve estimates over direct questioning methods when comparing with known truth. These results may reflect difficulties in implementation or comprehension of the LR approach, which is inherently complex. Adjustments to delivery procedures may improve LR's usefulness. Further investigation of the cognitive processes of participants in answering LR surveys is warranted. © 2018 The Author(s).
Journal of Global Health. 2017 Jun; 7(1):010418.BACKGROUND: Preventive and curative medical interventions can reduce child mortality. It is important to assess whether there is gender bias in access to these interventions, which can lead to preferential treatment of children of a given sex. METHODS: Data from Demographic and Health Surveys carried out in 57 low- and middle-income countries were used. The outcome variable was a composite careseeking indicator, which represents the proportion of children with common childhood symptoms or illnesses (diarrhea, fever, or suspected pneumonia) who were taken to an appropriate provider. Results were stratified by sex at the national level and within each wealth quintile. Ecological analyses were carried out to assess if sex ratios varied by world region, religion, national income and its distribution, and gender inequality indices. Linear multilevel regression models were used to estimate time trends in careseeking by sex between 1994 and 2014. FINDINGS: Eight out of 57 countries showed significant differences in careseeking; in six countries, girls were less likely to receive care (Colombia, Egypt, India, Liberia, Senegal and Yemen). Seven countries had significant interactions between sex and wealth quintile, but the patterns varied from country to country. In the ecological analyses, lower careseeking for girls tended to be more common in countries with higher income concentration (P = 0.039) and higher Muslim population (P = 0.006). Coverage increased for both sexes; 0.95 percent points (pp) a year among girls (32.9% to 51.9%), and 0.91 pp (34.8% to 52.9%) among boys. CONCLUSION: The overall frequency of careseeking is similar for girls and boys, but not in all countries, where there is evidence of gender bias. A gender perspective should be an integral part of monitoring, accountability and programming. Countries where bias is present need renewed attention by national and international initiatives, in order to ensure that girls receive adequate care and protection.
Severely biased review of studies assessing the risk of venous thrombosis in users of drospirenone-containing oral contraceptives.
BJOG. 2018 Jul; 125(8):929-931.In a recent review, Larivee et al. attempted to categorise 17 observational studies specifically assessing the risk of venous thrombosis (VTE) in users of combined oral contraceptives (COCs) with drospirenone.(1) Such a review is relevant due to the divergent results in these studies, which could be due to bias in some of them. The review concluded that the risk of VTE with drospirenone-containing COCs remains unknown, and that the highest-quality studies suggest there are no or slightly increased harmful effects. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
European Journal of Contraception and Reproductive Health Care. 2018 Apr; 23(2):166-168.Add to my documents.
Concordance of self-reported hormonal contraceptive use and presence of exogenous hormones in serum among African women.
Contraception. 2018 Apr; 97(4):357-362.OBJECTIVES: Studies that rely on self-report to investigate the relationship between hormonal contraceptive use and HIV acquisition and transmission, as well as other health outcomes, could have compromised results due to misreporting. We determined the frequency of misreported hormonal contraceptive use among African women with and at risk for HIV. STUDY DESIGN: We tested 1102 archived serum samples from 664 African women who had participated in prospective HIV prevention studies. Using a novel high-performance liquid chromatography-mass spectrometry assay, we quantified exogenous hormones for injectables (medroxyprogesterone acetate or norethisterone), oral contraceptives (OC) (levonorgestrel or ethinyl estradiol) and implants (levonorgestrel or etonogestrel) and compared them to self-reported use. RESULTS: Among women reporting hormonal contraceptive use, 258/358 (72%) of samples were fully concordant with self-report, as were 642/744 (86%) of samples from women reporting no hormonal contraceptive use. However, 42/253 (17%) of samples from women reporting injectable use, 41/66 (62%) of samples from self-reported OC users and 3/39 (8%) of samples from self-reported implant users had no quantifiable hormones. Among self-reported nonusers, 102/744 (14%) had >/=1 hormone present. Concordance between self-reported method and exogenous hormones did not differ by HIV status. CONCLUSION: Among African women with and at risk for HIV, testing of exogenous hormones revealed agreement with self-reported contraceptive use for most women. However, unexpected exogenous hormones were identified among self-reported hormonal contraceptive users and nonusers, and an important fraction of women reporting hormonal contraceptive use had no hormones detected; absence of oral contraceptive hormones could be due, at least in part, to samples taken during the hormone-free interval. Misreporting of hormonal contraceptive use could lead to biased results in observational studies of the relationship between contraceptive use and health outcomes. IMPLICATIONS: Research studies investigating associations between hormonal contraceptive use and HIV should consider validating self-reported use by objective measures; because both overreporting and underreporting of use occur, potential misclassification based on self-report could lead to biased results in directions that cannot be easily predicted. Copyright (c) 2018 Elsevier Inc. All rights reserved.
Economics and Human Biology. 2017 Nov; 27(Part A):248-260.This paper estimates the causal impact of being HIV positive on individual employment status using a recursive bivariate probit with male circumcision as the instrument to overcome the endogeneity arising from simultaneity bias. The results show that being HIV positive reduces the probability of being employed by 5 percentage points among males in Uganda. The effect is greater for individuals employed in manual labor than non-manual labor. When limiting the sample to mainly individuals employed in subsistence agriculture, we find a 4 percentage point reduction in the likelihood of employment, suggesting that the effect occurs primarily through reductions in labor supply as opposed to demand. This is supported by additional analysis using univariate probit regressions to assess the association between different levels of HIV illness (as measured by CD4 cell count) and the likelihood of employment. The magnitude of the association increases as CD4 cell count decreases. Having a CD4 cell count of 200permm³ or below is associated with a 9 percentage point reduction in employment compared to individuals with CD4 cell counts above 200permm³.
A Risk-based Model for Predicting the Impact of using Condoms on the Spread of Sexually Transmitted Infections.
Infectious Disease Modelling. 2017 Feb; 2(1):100-112.We create and analyze a mathematical model to estimate the impact of condom-use and sexual behavior on the prevalence and spread of Sexually Transmitted Infections (STIs). STIs remain a significant public health challenge globally with a high burden of some Sexually Transmitted Diseases (STDs) in both developed and undeveloped countries. Although condom-use is known to reduce the transmission of STIs, there are a few quantitated population-based studies on the protective role of condom-use in reducing the incidence of STIs. The number of concurrent partners is correlated with their risk of being infectious by a STI such as chlamydia, gonorrhea, or syphilis. We define a Susceptible-Infectious-Susceptible (SIS) model that distributes the population by the number of concurrent partners. The model captures the multi-level heterogeneous mixing through a combination of biased (preferential) and random mixing between individuals with different risks, and accounts for differences in condom-use in the low- and high-risk populations. We use sensitivity analysis to assess the relative impact of high-risk people using condom as a prophylactic to reduce their chance of being infectious, or infecting others. The model predicts the STI prevalence as a function of the number of partners that a person has, and quantifies how this distribution changes as a function of condom-use. Our results show that when the mixing is random, then increasing the condom-use in the high-risk population is more effective in reducing the prevalence than when many of the partners of high-risk people have high risk. The model quantified how the risk of being infected increases for people who have more partners, and and the need for high-risk people to consistently use condoms to reduce their risk of infection.
European Journal of Contraception and Reproductive Health Care. 2017 Oct; 22(5):396-397.Add to my documents.
Demographic Research. 2017 Jul 18; 37(6):129-146.BACKGROUND Cross-sectional analyses of the relationship between contraceptive prevalence and the total fertility rate of developing countries show the expected strong negative correlation. However, this correlation is much weaker in sub-Saharan Africa than in the developing world as a whole. OBJECTIVE This paper aims to explain the unexpected weak effect of contraceptive use on fertility in sub-Saharan African countries by using different regression models to obtain unbiased effects. METHOD Using DHS survey data from 40 developing countries, the analysis consists of three steps: 1) examine the conventional cross-sectional TFR-CPR relationship by region at the time of the latest available surveys; 2) remove known technical flaws in the comparisons of fertility and contraceptive prevalence; and 3) analyze multiple observations of TFR and CPR per country using pooled OLS and fixed effect regressions. RESULTS The conventional cross-sectional analyses produce biased results, in part because technical factors, in particular postpartum overlap, create a downward bias in the effect of contraceptive prevalence on fertility in sub-Saharan Africa. In addition, and more importantly, the cross-sectional regression OLS parameters have a bias due to confounding country fixed effects. Technical adjustments and the use of fixed-effect models remove these biases. CONCLUSION A rise in contraceptive prevalence among fecund women has the same average effect on fertility in sub-Saharan Africa as in other regions of the developing world.
JAMA Internal Medicine. 2017 Sep 1; 177(9):1273-1286.Importance: Despite 3 decades of study, there remains ongoing debate regarding whether vasectomy is associated with prostate cancer. Objective: To determine if vasectomy is associated with prostate cancer. Data Sources: The MEDLINE, EMBASE, Web of Science, and Scopus databases were searched for studies indexed from database inception to March 21, 2017, without language restriction. Study Selection: Cohort, case-control, and cross-sectional studies reporting relative effect estimates for the association between vasectomy and prostate cancer were included. Data Extraction and Synthesis: Two investigators performed study selection independently. Data were pooled separately by study design type using random-effects models. The Newcastle-Ottawa Scale was used to assess risk of bias. Main Outcomes and Measures: The primary outcome was any diagnosis of prostate cancer. Secondary outcomes were high-grade, advanced, and fatal prostate cancer. Results: Fifty-three studies (16 cohort studies including 2563519 participants, 33 case-control studies including 44536 participants, and 4 cross-sectional studies including 12098221 participants) were included. Of these, 7 cohort studies (44%), 26 case-control studies (79%), and all 4 cross-sectional studies were deemed to have a moderate to high risk of bias. Among studies deemed to have a low risk of bias, a weak association was found among cohort studies (7 studies; adjusted rate ratio, 1.05; 95% CI, 1.02-1.09; P < .001; I2 = 9%) and a similar but nonsignificant association was found among case-control studies (6 studies; adjusted odds ratio, 1.06; 95% CI, 0.88-1.29; P = .54; I2 = 37%). Effect estimates were further from the null when studies with a moderate to high risk of bias were included. Associations between vasectomy and high-grade prostate cancer (6 studies; adjusted rate ratio, 1.03; 95% CI 0.89-1.21; P = .67; I2 = 55%), advanced prostate cancer (6 studies; adjusted rate ratio, 1.08; 95% CI, 0.98-1.20; P = .11; I2 = 18%), and fatal prostate cancer (5 studies; adjusted rate ratio, 1.02; 95% CI, 0.92-1.14; P = .68; I2 = 26%) were not significant (all cohort studies). Based on these data, a 0.6% (95% CI 0.3%-1.2%) absolute increase in lifetime risk of prostate cancer associated with vasectomy and a population-attributable fraction of 0.5% (95% CI 0.2%-0.9%) were calculated. Conclusions and Relevance: This review found no association between vasectomy and high-grade, advanced-stage, or fatal prostate cancer. There was a weak association between vasectomy and any prostate cancer that was closer to the null with increasingly robust study design. This association is unlikely to be causal and should not preclude the use of vasectomy as a long-term contraceptive option.
Health impact of catch-up growth in low-birth weight infants: systematic review, evidence appraisal, and meta-analysis.
Maternal and Child Nutrition. 2017 Jan; 13(1)This study aimed to systematically review and appraise evidence on the short-term (e.g. morbidity, mortality) and long-term (obesity and non-communicable diseases, NCDs) health consequences of catch-up growth (vs. no catch-up growth) in individuals with a history of low birth weight (LBW).We searched MEDLINE, EMBASE, Global Health, CINAHL plus, Cochrane Library, ProQuest Dissertations and Thesis and reference lists. Study quality was assessed using the risk of bias assessment tool from the Agency for Health Care Research and Quality, and the evidence base was assessed using the GRADE tool. Eight studies in seven cohorts (two from high-income countries, five from low-middle-income countries) met the inclusion criteria for short-term (mean age: 13.4 months) and/or longer-term (mean age: 11.1 years) health outcomes of catch-up growth, which had occurred by 24 or 59 months. Of five studies on short-term health outcomes, three found positive associations between weight catch-up growth and body mass and/or glucose metabolism; one suggested reduced risk of hospitalisation and mortality with catch-up growth. Three studies on longer-term health outcomes found catch-up growth were associated with higher body mass, BMI or cholesterol. GRADE assessment suggested that evidence quantity and quality were low. Catch-up growth following LBW may have benefits for the individual with LBW in the short term, and may have adverse population health impacts in the long-term, but the evidence is limited. Future cohort studies could address the question of the consequences of catch-up growth following LBW more convincingly, with a view to informing future prevention of obesity and NCDs. (c) 2016 John Wiley & Sons Ltd. (c) 2016 John Wiley & Sons Ltd.
Could misreporting of condom use explain the observed association between injectable hormonal contraceptives and HIV acquisition risk?
Contraception. 2017 Apr; 95(4):424-430.Objective some observational studies have suggested an association between the use of hormonal contraceptives (HC) and HIV acquisition. One major concern is that differential misreporting of sexual behavior between HC users and nonusers may generate artificially inflated risk estimates. Study design We developed an individual-based model that simulates the South African HIV serodiscordant couples analyzed for HC-HIV risk by Heffron et al. (2012). We varied the pattern of misreporting condom use between HC users and nonusers and reproduced the trial data under the assumption that HC use is not associated with HIV risk. The simulated data were analyzed using Cox proportional hazards models, adjusting for the reported level of condom use. Results If HC users overreport condom use more than nonusers, an apparent excess risk could be observed even without any biological effect of HC on HIV acquisition. With 45% overreporting by HC users (i.e., 9 out of every 20 sex acts reported with condoms are actually unprotected) and accurate condom reporting by nonusers, a true null effect can be inflated to give an observed hazard ratio ( ) of 2.0. In a different population with lower overall reported condom use, artificially high s can only be generated if non-HC users underreport condom use. Conclusion Differential condom misreporting can theoretically produce inflated values for an association between HC and HIV even without a true association. However, to produce a doubling of HIV risk that is entirely spurious requires substantially different levels of misreporting among HC users and nonusers, which may be unrealistic. Implications Considerably differential amounts of condom use misreporting by HC users and nonusers would be needed to produce entirely spurious observed levels of excess HIV acquisition risk among HC users when there is actually no true association.
Education Economics. 2017 Mar 4; 25(2):183-204.This study uses data on educational expenditure, including specific types of educational expenditure, from the 2009 Socioeconomic Survey of Thailand to investigate gender bias in the allocation of educational resources. Empirical Engel’s curves are estimated to test for gender bias. The results show that girls receive more education expenditure than boys. The most likely explanations for this gender bias are: (1) According to the Thai cultural tradition, daughters are expected to be the main caregivers of their elderly parents and (2) wage incomes of daughters are more reliable sources of remittances for parents than the wage incomes of sons.
Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries.
Human Resources For Health. 2017 Apr 13; 15(1):29.BACKGROUND: Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings. METHODS: Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC. RESULTS: We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels. CONCLUSIONS: Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.
Quantitative bias analysis of a reported association between perfluoroalkyl substances (PFAS) and endometriosis: The influence of oral contraceptive use.
Environment International. 2017 Jul; 104:118-121.An association between serum levels of perfluoroalkyl substances (PFAS) and endometriosis has recently been reported in an epidemiologic study. Oral contraceptive use to treat dysmenorrhea (pelvic pain associated with endometriosis) could potentially influence this association by reducing menstrual fluid loss, a route of excretion for PFAS. In this study, we aimed to evaluate the influence of differential oral contraceptive use on the association between PFAS and endometriosis. We used a published life-stage physiologically based pharmacokinetic (PBPK) model to simulate plasma levels of perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) from birth to age at study participation (range 18-44years). In the simulated population, PFAS level distributions matched those for controls in the epidemiologic study. Prevalence and geometric mean duration (standard deviation [SD]) of oral contraceptive use in the simulated women were based on data from the National Health and Nutrition Examination Survey; among the women with endometriosis the values were, respectively, 29% and 6.8 (3.1) years; among those without endometriosis these values were 18% and 5.3 (2.8) years. In simulations, menstrual fluid loss (ml/cycle) in women taking oral contraceptives was assumed to be 56% of loss in non-users. We evaluated the association between simulated plasma PFAS concentration and endometriosis in the simulated population using logistic regression. Based on the simulations, the association between PFAS levels and endometriosis attributable to differential contraceptive use had an odds ratio (95% CI) of 1.05 (1.02, 1.07) for a loge unit increase in PFOA and 1.03 (1.02, 1.05) for PFOS. In comparison, the epidemiologic study reported odds ratios of 1.62 (0.99, 2.66) for PFOA and 1.25 (0.87, 1.80) for PFOS. Our results suggest that the influence of oral contraceptive use on the association between PFAS levels and endometriosis is relatively small.
BMC Health Services Research. 2017 Apr 12; 17(1):268.BACKGROUND: Health service providers can restrict access to contraceptives through their own imposed biases about method appropriateness. In this study, provider biases toward contraceptive service provision among urban Nigerian providers was assessed. METHODS: Health providers working in health facilities, as well as pharmacists and patent medical vendors (PMV), in Abuja, Benin City, Ibadan, Ilorin, Kaduna, and Zaria, were surveyed in 2011 concerning their self-reported biases in service provision based on age, parity, and marital status. RESULTS: Minimum age bias was the most common bias while minimum parity was the least common bias reported by providers. Condoms were consistently provided with the least amount of bias, followed by provision of emergency contraception (EC), pills, injectables, and IUDs. Experience of in-service training for health facility providers was associated with decreased prevalence of marital status bias for the pill, injectable, and IUD; however, training experience did not, or had the opposite effect on, pharmacists and PMV operator's reports of service provision bias. CONCLUSIONS: Provider imposed eligibility barriers in urban study sites in Nigeria were pervasive - the most prevalent restriction across method and provider type was minimum age. Given the large and growing adolescent population - interventions aimed at increasing supportive provision of contraceptives to youth in this context are urgently needed. The results show that the effect of in-service training on provider biases was limited. Future efforts to address provider biases in contraceptive service provision, among all provider types, must find creative ways to address this critical barrier to increased contraceptive use.
Drospirenone-containing Oral Contraceptive Pills and the Risk of Venous Thromboembolism: A Systematic Review of Observational Studies.
BJOG. 2017 Sep; 124(10):1490-1499.BACKGROUND: The effects of fourth generation drospirenone-containing combined oral contraceptives (COCs) on the risk of venous thromboembolism (VTE) are controversial. OBJECTIVES: To assess the methodological strengths and limitations of the evidence on the VTE risk of these COCs. SEARCH STRATEGY: We searched CINAHL, the Cochrane Library, EMBASE, HealthStar, Medline, and the Science Citation Index. SELECTION CRITERIA: Studies were included if they were cohort and case-control studies, reported a venous thrombotic outcome, had a comparator group, reported an effect measure of the association of interest, and were published in English or French. DATA COLLECTION AND ANALYSIS: We assessed study quality using the ROBINS-I tool and assessed the presence of four common sources of bias: prevalent user bias, inappropriate choice of comparator, VTE misclassification, and confounding. MAIN RESULTS: Our systematic review included 17 studies. The relative risks of VTE associated with drospirenone- versus second generation levonorgestrel-containing COCs ranged from 1.0 to 3.3. Based on ROBINS-I, 3 studies had a moderate risk, 10 had a serious risk, and 4 had a critical risk. Nine studies included prevalent users, 4 included inappropriate comparators, 4 had VTE misclassification, and 5 did not account for 2 or more important confounders. The 3 highest quality studies had relative risks ranging from 1.0 to 1.57. CONCLUSIONS: Due to the methodological limitations of the individual studies, the VTE risk of drospirenone-containing COCs remains unknown. The highest quality studies suggest no or slightly increased harmful effects, but their confidence limits do not rule out an almost doubling of the risk. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
[Breastfeeding indicators produced at time of vaccination in four Primary Care Centres in southern Santiago, Chile] Indicadores de Lactancia Materna obtenidos en el momento de la vacunacion en cuatro Centros de Salud Familiar de la zona Sur de Santiago.
Revista Chilena de Pediatria. 2016 Jan-Feb; 87(1):11-7.OBJECTIVES: To compare official breastfeeding (BF) data with those obtained by interviews conducted during regular vaccination visits. SUBJECTS AND METHOD: A pilot descriptive study with convenience sampling was conducted by interviewing guardians of children attending vaccination in four Primary Care Centres in south Santiago. BF prevalence indicators were calculated and stratified by age and education of mothers. A comparison was made between the results and the official ones reported by each Centre. Chi-squared (X2) was calculated to evaluate differences (P<.05) RESULTS: A total of 1990 cases were analysed, in which exclusive BF prevalence was 43.4%, 34.2% and 8.8%, at 2, 4, and 6 months, respectively. At the sixth month, official data (41%) was significantly higher (P<.001). Mothers with less than 12 years of schooling have a lower prevalence of exclusive BF at the 4th month than those with higher education (28.4% vs. 37.8%, respectively, P<.05). CONCLUSIONS: Even considering the small size of the sample studied, exclusive BF prevalence obtained is surprisingly lower than official reported data. That difference might be explained by: (a) children brought to vaccinations are roughly two fold the number brought to well-child clinics and, (b) potential bias in official data obtained by staff in charge of promotion and education on BF practices, which could distort the results. Further studies are needed to improve the methodology for collecting and analysis BF data. Copyright (c) 2015 Sociedad Chilena de Pediatria. Publicado por Elsevier Espana, S.L.U. All rights reserved.
Contraception. 2016 Oct; 94(4):381-383.Add to my documents.