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Long-acting and permanent contraception: An international development, service delivery perspective.
Journal of Midwifery and Women's Health. 2007 Jul-Aug; 52(4):361-367.Recent scientific findings about long-acting and permanent methods of contraception underscore their safety, effectiveness, and wide eligibility for individuals who desire them. This has led to new guidance from the World Health Organization to inform national policies, guidelines, and standards for service delivery. Although developing countries have made much progress in expanding the availability and use of family planning services, the need for effective contraception in general (and long-acting and permanent methods in particular) is large and growing because the largest cohorts in human history are entering their reproductive years. More than half a billion people will use contraception in developing countries (excluding China) by 2015, an increase of 200 million over levels of use in 2000. The health, development, and equity rationales that historically have underpinned and energized the international family planning effort remain valid and relevant today. Despite the other compelling challenges faced by the international health community, the need to make family planning services more widely available is pressing and should remain a priority. (author's)
World Health Organization Technical Report Series. 1981; (670):1-120.This report includes the collective views of a World Health Organization (WHO) Scientific Group on Research on the Menopause that met in Geneva during December 1980. It includes information on the following: 1) the endocrinology of the menopause and the postmenopausal period (changes in gonadotropins and estrogens immediately prior to the menopause and changes in gonadotropin and steroid hormone levels after the menopause); 2) the age distribution of the menopause (determining the age at menopause, factors influencing the age at menopause, and the range of ages at menopause and the definition of premature and delayed menopause); 3) sociocultural significance of the menopause in different settings; 4) symptoms associated with the menopause (vasomotor symptoms, psychological symptoms, disturbances of sexuality, and insomnia); 5) disorders resulting from, or possibly accelerated by, the menopause (osteoporosis, atherosclerotic cardiovascular disease, and arthritic disorders); 6) risks, with particular reference to neoplasia, of therapeutic estrogens and progestins given to peri- and postmenopausal women (endometrial cancer, breast cancer, and gallbladder disease); 7) fertility regulating methods for women approaching the menopause (fertility and the need for family planning in women approaching the menopause, problems of family planning in perimenopausal women, and considerations with regard to individual methods of family planning in women approaching the menopause); and 8) estrogen and the health care management of perimenopausal and postmenopausal women. At this time some controversy exists as to whether there is a menopausal syndrome of somatic and psychological symptoms and illness. There are virtually no data on the age distribution of the menopause and no information on its sociocultural significance in the developing countries. The subject of risks and benefits of estrogen therapy in peri- and postmenopausal women is of much importance in view of the large number of prescriptions issued for this medication in developed countries, which indicates their frequrnt use, and the different interpretations and opinions among epidemiologists and clinicians on both past and current studies on this subject. Specific recommendations made by the Scientific Group appear at the end of each section of the report. The following were among the general recommendations made: WHO sponsored research should be undertaken to determine the impact on health service needs of the rapidly increasing numbers of postmenopausal women in developing countries; uniform terminology should be adopted by health care workers with regard to the menopause; uniform endocrine standards should be developed which can be applied to the description of peri- and postmenopausal conditions and diseases; and descriptive epidemiological studies of the age at menopause should be performed in a variety of settings.
[Unpublished] . 10,  p.Based upon United Nations medium population projections, the population of developing countries will grow from 4,086 million in 1990, to 5,000 million by the year 2000. To meet this medium-level projection, 186 million contraceptive users must be added for a total 567 million in addition to increased contraceptive prevalence of 59% from 51%. This study estimates the number of contraceptive users, acceptors, and cost of contraceptive commodities needed to limit growth to this medium projection. Needs are estimated by country and method for 1990, 1995 and 2000, for medium, high, and low population projections. The number of contraceptive users required to reach replacement fertility is also calculated. Results are based upon the number of women aged 15-49, percent married, number married ages 15-49, and the proportion of couples using contraception. Estimation methodology is discussed in detail. Estimated users of respective methods in millions are 150 sterilizations, 333 IUD insertions, 663 injections, 7,589 cycles of pills, and 30,000 condoms. Estimated commodity costs will grow from $399 million in 1990 to $627 million in 2000, for a total $5.1 billion over the period. Pills will be the most expensive at $1.9 billion, followed by sterilizations at $1.4 billion, condoms $888 million, injectables $594 million, and IUDs $278 million. Estimated costs for commodities purchased in the U.S. show IUDs and condoms to be significantly more expensive, but pills as cheaper. With donors paying for approximately 25% of public sector commodity costs, developing country governments will need to pay $4.2 billion of total costs in the absence of increased commercial/private sector and donor support.
STUDIES IN FAMILY PLANNING. 1991 Jan-Feb; 22(1):1-18.A study investigative the pros and cons of financial payments for sterilizations to clients, medical personnel, and agents who motivate and refer clients was conducted by the government of Bangladesh in conjunction with the World Bank. Results indicate that Bangladeshi men and women opt to be sterilized both voluntarily and after consideration of the nature and implications of the procedure. Clients were also said to be knowledgeable of alternate methods of controlling fertility. A high degree of client satisfaction was noted overall with, however, 25% regret among those clients with less than 3 children. Money is a contributing factor in a large majority of cases, though dominating as motivation for a small minority. Financial payments to referrers have sparked a proliferation of many unofficial, self-employed agents, especially men recruiting male sterilization. Targeting especially poor potential clients, these agents focus upon sterilization at the expense of other fertility regulating methods, and tend to minimize the cons of the process. Examples of client cases and agents are included in the text along with discussion of implications from study findings.
[Unpublished] 1987. 7 p.During the July 21-24 trip to Burundi, discussions were held about possible Association for Voluntary Surgical Contraception (AVSC) assistance in creating a training center at the University Hospital which could serve as a site for training medical personnel from Burundi and other French-speaking African nations. Practical training is urgently needed at this time to allow health personnel to feel comfortable about dispensing a wide range of contraceptive methods/information. A great need exists for the training of nurses in IUD insertion and for copper-T commodities. Family planning method acceptance is growing steadily: the number is said to double every 6 months. As yet, voluntary surgical contraception plays a minor role and is available only at a limited number of centers. As previously reported, several donors, including the UN Fund for Population Assistance, World Bank, and the African Development Bank, are involved in activities/proposals related to maternal/child health and family planning. The major objective of AVSC assistance to the Ministry of Public Health is to increase access to VSC by integrating quality services into ongoing maternal/child health/family planning activities in 4 regional referral hospitals. The project is expected to last for 4 years with a total budget of slightly over $200,000. During this visit, the basics were worked out for a program in which AVSC would provide assistance for training 10 physicians/year in minilap (both postpartum and interval) using local anesthesia. Trainees would be residents and interns and, if possible, physicians from government facilities. It is hoped that a training program document can be developed for presentation at the December 1987 meeting of AVSC's International Committee. The site visit was useful to the effort of moving the pending project with the Ministry of Public Health along and for discussing possible cooperation with the University Hospital. Program success is likely for several reasons: the Ministry of Public Health generally is favorable and supportive; chances for "institutionalization" are good; the basic hospital infrastructure is sound; and the rising demand for VSC is recognized by health officials and service providers.
Association for Voluntary Sterilization - Consultant Team. Trip report: the People's Republic of China, Beijing, Chongqing, Wuhan, Guangzhou, June 19-30, 1985.
[Unpublished] 1985. 41,  p.The Association for Voluntary Sterilization consultant team visited Beijing, Chongqing, Wuhan and Guangzhou, China in June 1985, to review innovative nonsurgical methods of male and female sterilization. There are 2 variations on vasectomy, performed with special clamps that obviate a surgical incision. The 1st is a circular clamp for grasping the vas through the skin, and the 2nd is a small, curved, sharp hemostat for puncturing the skin and the vas sheath, used for ligation. Vas occlusion with 0.02 ml of a solution of phenol and cyanoacrylate has been performed on 500,000 men since 1972. The procedure is done under local anesthesia, and is controlled by injecting red and blue dye on contralateral sides. If urine is not brown, vasectomy by ligature is performed. The wound is closed with gauze only. Semen analysis is not done, but patients are advised to use contraception for the 1st 10 ejaculations. Pregnancy rates after vasectomy by percutaneous injection were reported as 0 in 5 groups of several hundred men each, 11.4% in 1 group and 2.4% in another group. The total complication rate after vasectomy by clamping was 1.8% in 121,000 men. 422 medical school graduates with surgical training have been certified in this vasectomy method. Chinese men are pleased with this method because it avoids surgery by knife, and asepsis, anesthesia and counseling are excellent. Female sterilization by blind transcervical delivery of a phenol-quinacrine mixture has been done on 200,000 women since 1970 by research teams in Guangzhou and Shanghai. A metal cannula is inserted into the tubal opening, tested for position by an injection of saline, and 0.1-0.12 ml of sclerosing solution is instilled. Correct placement is verified by x-ray, an IUD is inserted, and after 3 months a repeat hysteroscopy is done to test uterine pressure. Pregnancy rates have been 1-2.5%, generally in the 1st 2 years. Although this technique is tedious, requiring great skill and patient cooperation, it can be mastered by paramedicals. The WHO is assisting the Chinese on setting up large studies on safety and effectiveness, as well as toxicology studies needed, to export the methods to other countries.
Sterilizations by sex and percentages of: male to female sterilizations and total number of sterilizations as percentage of total new acceptors. 1979-1984.
[Unpublished] . 3 p.This is an International Planned Parenthood Federation (IPPF) collection of data detailing numbers of sterilizations in each country of the western hemisphere from 1979 to 1985. The table presents sterilizations among males and females, total number of sterilizations, ratio of male to female expressed in percentages, and ratio of sterilizations to new acceptors also expressed as percentages. The countries with the numbers over 10,000 in 1986 were Columbia, Guatemala and the Dominican Republic. Countries with 1000 to 9999 were U.S., Honduras, Mexico, El Salvador, Ecuador and Brazil, in order. Most nations reported 5 to 10 times more female than male sterilizations. The exception was the U.S., with 10 times more vasectomies in the latter years. The total reported ranged from 63,400 in 1980 to 94,448 in 1985.
Lancet. 1985 May 4; 1(8436):1046.As part of a study on acute febrile pelvic inflammatory disease and IUDs, reported elsewhere, a significantly lower risk of PID was observed in women using injectable contraceptives. The World Health Organization coordinated the multinational case-control study in 1979-79. Diagnostic criteria were fever, suprapubic tenderness with guarding, cervical or adnexal tenderness or a pelvic mass. 319 cases and 639 matched controls were matched for age, parity, marital status and hospital status. Data were taken from questionnaires. 10 cases (3.1%) currently used injectable contraceptives, mainly Depo-Provera, compared to 38 controls (6.0%). Thus the risk of getting PID was half as great among injectable users, similar in magnitude to risks reported for women using oral contraceptives, barrier methods and sterilization in developing countries.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION. 1986 Feb; 79(2):75-6.275 laparoscopic tubal ligations were done safely and economically at the Planned Parenthood of Memphis outpatient clinic from May 1983 to June 1985. Patients were carefully selected and counselled, eliminating those with previous abdominal surgery, excluding cesarean section, and those with ongoing pregnancy or serious gynecological or medical problems. The trained staff of experienced laparoscopic surgeons and certified registered nurse anesthetists practiced emergency procedures before surgery. Anesthesia was a minimal amount of nalbuphine (Nubain) 20 to 40 mg and droperidol (Inapsine) 1.25 to 2.5 mg; or fentanyl 0.1 to 0.25 mg and droperidol 1.25 to 2.5 mg; occasionally nitrous oxide inhalation. Some women received droperidol 1.25 to 2.5 mg or diazepam 2.5 to 5 mg beforehand. The laporoscopic procedure, performed through a small intraumbilical incision, employed the fallop ring. The incision was closed with 000 Dexon subcuticular sutures. There were minor side effects in 23: nausea in 20, vomiting in 2 and wound infection in 1. Two pregnancies occurred: 1 was not detected in the preliminary pregnancy test and the other was a procedure failure. The sterilization program is considered safe and resonably priced, $450 compared to $1150 to 1469 in area hospitals outpatient clinics.
Lancet. 1984 Jul 21; 2(8395):144-5.The objective of the World Health Organization (WHO) project, an international, prospective study conducted by centers in England, India, Columbia, Nigeria, and the Philippines, was to investigate the effects of tubal occlusion on the mental and physical health and psychosexual and menstrual functioning of women choosing to undergo the procedure for contraceptive purposes only. A subsequent report presents details and results of the English component of the study. 2 groups of healthy multiparous women having either interval sterilization (at least 6 months since an obstetric event) or postpartum sterilization (within 72 hours of delivery) were recruited. For each group, a control group was recruited from women using or planning to use nonpermanent contraceptive methods. All women were interviewed preoperatively and again 6 weeks and 6 months after the operation by standardized techniques. The results showed that sterilized women did not differ from the control samples in mental state, as assessed by the Present State Examination or in subjectively assessed mental or physical health or abdominal pain. More sterilization subjects than control subjects reported improvement in sexual satisfaction at the later follow-up. Many of the subjects reporting adverse effects at follow-up had revealed disturbances at the initial asssessment. All these women had at least 2 living children. They were women living in stable marriages or other relationships that had lasted an average of over 9 years. They were free from physical or mental ill health before sterilzation. They had their sterilizations voluntarily and solely for the purpose of keeping their families small. It comes as no surprise that, relative to a general population sample, the mental state of sterilized women in the study actually seemed to improve. A need exists for methodoloically sound studies that would identify social and psychological conditions under which sterilization might have ill effects.
IPPF Medical Bulletin. April 1973; 7(2):3-4.A 2nd international conference on sterilization was held by the International Project of the Association for Voluntary Sterilization in Geneva from February 26 to March 1, 1973. Both male and female sterilization were discussed. Techniques, side effects, and equipment for sterilization procedures were discussed. It was agreed that arbitrary parity and age requirements for sterilization are no longer necessary. Psychological aspects of the procedure were mentioned. It was pointed out that governments have an obligation to make available sterilization procedures as part of a total contraceptive program. Voluntary organization, particularly the International Planned Parenthood Federation, have an important place in sterilization work also.
In: Proceedings of the Fourth Annual Scientific Meeting of the Sudan Fertility Control Association held at Friendship Hall, Khartoum, 23 February 1983, edited by Dr. A/Salam Gerais. [Khartoum], Sudan, Sudan Fertility Control Association, 1983. 47-8.This paper consists of narrations to accompany a slide show. The slide illustrating the I.F.F.H. concept of data collection presents an integrated approach. Another slide shows the FIGO recommended case record, which is accepted by the WHO. A family planning question arises before birth and after birth of the child, female sterilization, number of additional children wanted. The slide on birth interval behavior enables the study of current birth outcome as a function of breastfeeding, family planning and prenatal visits. The last birth interval can be studied with maternity care monitoring, breastfeeding, and the status of the last surviving infant, a key variable. Once you know how many children you have reached, you can go forward and study the next birth interval. The slide showing the model approach enables determination of the current perinatal death from knowledge of the last birth interval and loss of the last live birth. With the increase of education, breastfeeding is reduced; family planning before current conception increases, with education it doubles; prenatal care increases with education. The birth interval is prolonged in cases of breastfeeding without family planning. If family planning is used, there is a marked prolongation of the birth interval. 63% of women attending the 11 centers surveyed in Indonesia wanted additional children among those who had 3 living children postpartum. Only 38% of those with 4 children wanted additional ones. This 50% cut is known as the 50% LDC and varies according to geographic location. Using the LDC (developing countries), one can determine the proportion of women who do not want to protect themselves postpartum, and the relation of having more living children to seeking contraceptive protection.