Thursday, 18 December 2014

The Gap Between Policy And Practice In Maternal Health And Maternal Mortality

As the UN Special Rapporteur on maternal mortality in India points out there is a 'yawning gulf between ... commendable maternal mortality policies and their urgent, focused, sustained, systematic and effective implementation.' Reproductive Health Matters explores the causes and impact of this gap, but also highlights hopeful signs of progress.

Two papers from India included in the issue capture both the good and bad news that characterise the gap between rhetoric and reality in maternal health and maternal mortality. In India a range of provisions to support better maternal nutrition and access to subsidised health care are required by law, but there is a wide gap between policy and practice. Preventable deaths are caused by several factors including a shortfall in antenatal care, delays in emergency obstetric care and inappropriate referral. Detailed case studies of women who died point to lack of accountability, discrimination on the grounds of poverty and caste, and according to Subha Sri Balakrishnan, author of one of the papers, "In some cases...quality of care (that) was so poor that it may be considered negligent."

Both papers follow subsequent action taken to seek government accountability and justice. In one paper, author Jameen Kaur, reports on the way in which a women's family sought redress in the courts, supported by human rights lawyers. The second paper details an investigation lead by Subha Sri Balakrishnan into maternal deaths in response to a public protest about local maternal deaths in Madhya Pradesh. The researchers presented their findings to district and state level health officials which led to some improvements in care.

Examples of using law to promote accountability and good practice are described in a paper from Latin America reporting on landmark decisions by the UN Committee on the Elimination of Discrimination Against Women (CEDAW) calling for appropriate maternal health care (Brazil) and decriminalisation of abortion to safeguard women's health (Peru). These are promising examples of the application of human rights to demand government responsibility for maternal deaths and to assert the rights of women not to die in pregnancy, childbirth and unsafe abortion.

Furthermore a new emphasis on evidence-based practice is described in several papers, providing grounds for optimism. It suggests there is a real desire to improve outcomes and the hope that new initiatives may have a greater chance of success in saving women's lives. Without the political commitment to addressing equity, however, important initiatives will continue to fail the poorest and most marginalised women. As one author notes, "The death of a woman due to pregnancy complications is not just a biological fact it is also a political choice."

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Wednesday, 17 December 2014

The Chilean abortion paradox

Legal restriction of abortion has a negative connotation since the idea of women resorting to illegal abortion -risking their own lives- is strongly rooted in the public opinion worldwide. However, a series of independently peer-reviewed articles, challenge this notion in some countries. The latest data in this subject have been discussed by the Chilean epidemiologist Elard Koch, Director of Research of the MELISA Institute, in the current issue of the official journal of the Chilean Society of Obstetrics and Gynecology. The research shows that not only abortion-related mortality continued its decreasing trend in Chile after its prohibition by law in 1989, but also hospital discharges due to abortion have significantly decreased during the last decade.

[Change in the Incidence of Hospital Discharges Due to Abortion in Chile between 2001 and 2010]
This official data was obtained from the Ministry of Health of the Government of Chile.
Credit: MELISA Institute

According to more recent evidence from official data, Chile displays a continuous decreasing trend of hospital discharges due to complications of abortions suspected to be illegally induced - represented by specific codes of the World Health Organisation classification - at a rate of 2% per year since 2001. In contrast, a decreasing trend was not observed in hospital discharges due to other types of abortion, such as spontaneous abortion or ectopic pregnancies, which have remained constant during the same period. The high quality of Chilean vital statistics indicates these findings are unlikely to be the result of an artifact of the registry system. Rather, a decrease in hospital discharges due to complications from illegal abortion appears to explain virtually all the reduction in hospital discharges due to any type of abortion in Chile during the last decade.

The Chilean experience represents a paradox in our times: even under a less permissive abortion legislation, maternal health indicators can be significantly improved by other factors, including a noteworthy reduction in mortality and morbidity associated to abortion.

In addition to a summary of the previously published research conducted at the MELISA Institute, showing that Chile is a paragon of maternal health in the entire American continent, the editorial article presents previously unpublished data of an ongoing study on the vulnerability profile of 3,134 Chilean women with unplanned pregnancies at risk of induced abortion. This research suggests that women at high risk of abortion display a vulnerability profile marked by coercion and fear, which together account for nearly 70% of the reasons for declaring the intention to terminate the pregnancy. Moreover, data suggest that support programs directed to vulnerable women can prevent most illegal abortions, with an outcome of live birth (with or without adoption) ranging between 69% and 94% depending on the risk group.

In Chile, it is estimated occur 13,000 to 18,000 illegal abortions each year, representing a death risk of 1 in 4 million women of fertile age and leading to about 16% of hospital discharges due to any type of abortion. It is thought that most illegal abortions are provoked through the self-administration of misoprostol. However, several authors agree that the Chilean progress in this matter is likely to be explained by the success of maternal health policy interventions, the access to modern methods of family planning, the increase in women's educational level and, more recently, to the emergence of support programs for vulnerable women with unplanned pregnancies at risk of abortion.


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Monday, 15 December 2014

New DNA test offers miscarriage clues

New research shows an alternative DNA test offers clinically relevant genetic information to identify why a miscarriage may have occurred years earlier. Researchers were able to identify chromosomal variants and abnormalities in nearly 50 percent of the samples. This first-of-its-kind study was conducted by researchers from Montefiore Medical Center and the Albert Einstein College of Medicine of Yeshiva University. The results were published in the March issue of Reproductive Biology and Endocrinology.

The technique used in this study, called rescue karyotyping, allows physicians to obtain important genetic information from tissue that had not been tested at the time of the miscarriage. As part of standard hospital protocol, tissue from miscarriages is embedded in paraffin for archival use and the karyotyping test is performed on DNA extracted from this tissue.

In this retrospective study of 20 samples from 17 women, genetic testing was successfully performed on 16 samples that had been archived for as long as four years. Of those samples, eight showed chromosomal variants and abnormalities. This is an important alternative when conventional karyotyping is not available or cannot be used for a specific sample.

"Given the ease of obtaining results, even if a delay in testing occurs, this new test may provide a useful technique to gain a better understanding as to why miscarriage occurs in some women," said Zev Williams, M.D., Ph.D., director, Program for Early and Recurrent Pregnancy Loss (PEARL), Montefiore and Einstein, assistant professor of obstetrics & gynecology and women's health and of genetics at Einstein, and corresponding author of the study. "I have seen women in tears because testing was not done at the time of the miscarriage and they feared they would never learn why it happened. Now we are able to go back and often get the answers we need."

One in five pregnancies ends in miscarriage, with the vast majority occurring in the first trimester. Recurrent miscarriage, which is defined as two or more miscarriages, occurs in up to 5 percent of couples attempting to conceive. Led by Dr. Williams, PEARL is comprised of a team of expert physicians, scientists, genetic counselors, nurses, technicians and staff members who work together to help these women maintain their pregnancies.

"Montefiore and Einstein have worked together to develop an innovative model based on research, which allows us to create novel diagnostic and treatment options and, in parallel, to quickly bring new advances to the clinic," said Dr. Williams. "This represents a new and emerging model in medicine - where the lab and clinic are brought closer in order to speed the pace of discovery and treatment."

"Most miscarriages are caused by an abnormal number of chromosomes in the embryo, accounting for up to 75 percent of first trimester losses," continued Dr. Williams. "This new test can help guide future treatment options but, more importantly, can also help alleviate some of the guilt and self-blame often associated with unexplained miscarriage and can close a door on a painful chapter in a woman's and couple's life."

Dr. Williams is a board certified obstetrician gynecologist with specialty training in reproductive endocrinology and infertility. He received his M.D. and Ph.D. degrees from the Mount Sinai School of Medicine and trained in Obstetrics and Gynecology at Harvard Medical School's Brigham and Women's Hospital and the Massachusetts General Hospital. Dr. Williams completed a fellowship in Reproductive Endocrinology and Infertility at Weill-Cornell Medical Center.


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Sunday, 14 December 2014

Early Medical Abortion Is "Safe And Effective"

Early medical abortion (EMA) using mifepristone is an effective option with a favourable safety profile, according to the authors of the first large-scale Australian study of the drug published online by the Medical Journal of Australia.

The study analysed the outcomes of over 13 000 women who had an EMA (up to 63 days gestation) between 2009 and 2011 using mifepristone, which is also known as RU486. The data were collected from women who had EMAs at Marie Stopes International Australia (MSIA) clinics. MSIA doctors are among around 200 doctors around Australia who are authorised to prescribe mifepristone for EMA.

Dr Philip Goldstone, medical director of MSIA, and coauthors found that clinic administration of mifepristone and later self-administration of buccal misoprostol to complete the abortion process at home had a low failure rate (3.5%), and low rates of haemorrhage (0.1%) and known or suspected infection (0.2%). One woman, who did not seek medical advice despite signs of infection for a number of days, died from sepsis.

The authors found that the process was also well tolerated, with most women reporting the experience to be as they had expected or better than expected. "While the potential risk of serious infection should be kept in mind and monitored, these results indicate that the mifepristone - buccal misoprostol regimen is an effective option for Australian women seeking an abortion up to 63 days of gestation."

In an editorial in the same issue, Cairns gynaecologists Professor Caroline de Costa and Dr Michael Carrette wrote that the findings backed up extensive overseas studies that had shown mifepristone to be both safe and effective for EMA.

However, they were concerned about some of the reported outcomes, which they said had implications for the national provision of mifepristone. It was vital that arrangements for emergency care in the rare event of complications were well documented. "Access to a telephone helpline alone is insufficient, especially for women in rural areas", they wrote.

Also, not all women were suitable candidates for the procedure because the abortion is usually completed at the woman's home. "Some women in poor socioeconomic circumstances and those who cannot find a suitable support person may be better served by surgical abortion", the authors wrote.

Some women, such as those travelling long distances, might need to have the medical abortion in a day surgery, they noted.

"We look forward to EMA being available to all Australian women who request it, and wish to see EMA recognised as being as safe as a surgical alternative."


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Friday, 12 December 2014

Medications Used To Treat Rheumatoid Arthritis May Affect Abortion Rate In Women

A new study published in the American College of Rheumatology (ACR) journal, Arthritis Care & Research, reveals that women with rheumatoid arthritis (RA) who were on methotrexate (MTX), a drug commonly used to reduce inflammation caused by RA, had lower rates of induced abortions compared to women with RA who were not exposed to the medication. Findings indicate that women with RA exposed to anti-tumor necrosis factor (anti-TNF) drugs may have increased abortion rates compared to unexposed women.

Experts estimate that 1.3 million U.S. adults have RA - an inflammatory disease where the immune system attacks the lining of the joints causing pain, swelling, stiffness, and ultimately may lead to loss of joint function. RA can affect women during their reproductive years, placing them at risk for unplanned pregnancies. In fact, one study has shown that up to half of pregnancies in North America are unplanned, and nearly half of these unintended pregnancies are terminated.

A 2003 study by Chakravarty et al. found that while 96% of rheumatologists in the U.S. had recommended birth control to female RA patients of childbearing age who were starting MTX, only 55% followed-up with patients regarding their use of contraceptives. "Women with RA who become pregnant may have disease-specific reasons which might influence their decision to end a pregnancy. Exposure to teratogenic drugs, such as MTX, which can affect the development of the fetus, is one such reason women with RA may choose an induced abortion," explains lead author, Dr. Évelyne Vinet, from the Montreal General Hospital of the McGill University Health Centre (MUHC) in Canada.

To expand evidence of induced abortion rates in women with RA exposed to MTX, the team performed a nested case-control study using Quebec's physician billing and hospitalization databases from 1996 to 2008. Women with RA who were between the ages of 15 and 45 were identified, with cases classified as women who had an induced abortion. MTX exposure was defined as filling a prescription for the drug less than 16 weeks prior to the date of abortion.

The team identified 112 women with RA who had an induced abortion (cases) and 5855 RA controls. Close to 11% of cases and 22% of controls were exposed to MTX. Compared to the unexposed controls, women with RA who were exposed to MTX had a lower rate of induced abortions. Further analysis found a potential increase in the rate of induced abortions among women exposed to anti-TNF drugs, such as Enbrel, Humira, and Remicade.

"Our study shows that women with RA who were on MTX had lower rates of induced abortions, while those exposed to anti-TNF medications had potentially higher abortion rates" concludes Dr. Vinet. "These findings highlight the importance of research on reducing the number of unplanned pregnancies in women with RA taking MTX or TNF inhibitors. Further examination of counseling practices and contraceptive use is warranted to further reduce the need for abortions in women with RA."


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Wednesday, 10 December 2014

Analysis Of Roe V. Wade Arrests Of And Forced Interventions On Pregnant Women

Last updated: 20 January 2013 at 12am PST Last updated: 20 Jan 2013 at 12am PST"Arrests of and Forced Interventions on Pregnant Women in the United States, 1973-2005: Implications for Women's Legal Status and Public Health," an article by Lynn M. Paltrow and Jeanne Flavin in the Journal of Health Politics, Policy and Law (volume 38, issue 2), offers a groundbreaking, in-depth look at criminal and civil cases in which a woman's pregnancy was a deciding factor leading to attempted and actual deprivations of her physical liberty.

As "personhood" measures are promoted and the fortieth anniversary of Roe v. Wade approaches, this article broadens the conversation from one about abortion to one about health policy and the legal status of pregnant women.

Paltrow and Flavin identified 413 cases involving arrests, detentions, and equivalent deprivations of pregnant women's physical liberty between 1973 and 2005. The authors examine key characteristics of the women and cases (including socioeconomic status and race); identify the legal claims used to support the arrests, detentions, and forced interventions; and explore the role that health care providers played in facilitating deprivations of pregnant women's liberty.

The data presented in this study challenge the idea that such interventions are rare and isolated events. Analysis reveals how existing laws, including feticide statutes, have been used to justify the arrests of pregnant women; provides evidence of what is likely to occur if personhood measures pass; and highlights the ways in which arrests and forced interventions undermine maternal, fetal, and child health.

Paltrow and Flavin's unparalleled documentation and analysis of cases offers a basis for building a shared political agenda that advances public health and ensures that pregnant women do not lose their civil and human rights.

Adapted by MNT from original media release

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Tuesday, 9 December 2014

Overestimation Of Abortion Deaths In Mexico Hinders Maternal Mortality Reduction Efforts

Multinational study finds that overestimation was due to discrepancies between data employed by IPAS-Mexico and official observed figures, as well as inadequate use of codes of the International Classification of Diseases

A collaborative study conducted in Mexico by researchers of the University of West Virginia-Charleston (USA), Universidad Popular Autónoma del Estado de Puebla (Mexico), Universidad de Chile and the Institute of Molecular Epidemiology of the Universidad Católica de la Santísima Concepción (Chile), revealed that IPAS-Mexico overestimated rates of maternal and abortion mortality up to 35% over the last two decades. The research, recently published in the International Journal of Women's Health highlights that Mexico shows a 82.7% reduction in maternal mortality between 1957 and 2010, from 216.6 to 37.5 deaths per 100,000 live births; for the period between 1990 and 2010, there was a 30.6% decrease in maternal mortality. "These results directly contradict the figures recently reported by researchers from the IPAS-Mexico, who not only fail to detect a significant progress in maternal health since 1990, but also substantially overestimated maternal mortality rates in Mexico" said Elard Koch, the Chilean epidemiologist that led the research.

The research group re-analyzed the official causes of maternal death registered in Mexico employing the International Classification of Diseases (ICD) of the World Health Organization and the figures of observed live births each year. In addition, the researchers directly compared the obtained data with the studies conducted by IPAS-Mexico, detecting that the discrepancies with the latter were due to errors in the numerator and denominator of maternal rates, as well as the inadequate use of ICD codes for death causes. "For instance, the nine codes related with death with abortive outcome are often grouped as if they were all associated to illegal induced abortion; this is clearly inappropriate since ectopic pregnancy, spontaneous abortion, abnormal products of conception and medical abortion are unrelated to illegal abortion" explained Byron Calhoun, specialist in Obstetrics and Gynecology from the West Virginia University-Charleston and co-author of the study.

The study also shows that abortion mortality in the whole Mexican country has decreased to the point that approximately 98% of total maternal deaths are related to hemorrhage during childbirth, hypertension and eclampsia, indirect causes and other pathological conditions. Koch explained that "given the low figures of abortion deaths observed in Mexico and previous results observed in the Chilean natural experiment published in May of this year in PLoS ONE, it is very improbable that changes in the legal status of abortion can elicit significant effects to decrease maternal mortality in these Latin American countries." For instance, out of the 1207 total maternal deaths registered in Mexico during 2009, only 25 could be attributable to induced abortion, resulting in a mortality rate of 0.97 per 100,000 live births. In the case of Chile, out of a total 43 maternal deaths observed during 2009, only 1 could be attributable to induced abortion, with a mortality rate of 0.39 per 100,000 live births. "To evaluate what are the main causes of maternal death is crucial to promote adequate Public Health policies and allocation of resources in developing countries that are never unlimited." Koch and Calhoun agreed.

A fact that concerned the researchers is that part of maternal deaths due to induced abortion in Mexico may be related to violence against women during pregnancy, whose prevalence has increased alarmingly in the country. Surveys of violence against women (Encuesta Nacional sobre Violencia contra las Mujeres, ENVIM) conducted in 2003 and 2006 show an increase in the prevalence of intimate partner violence from 9.8% to 33.3% and of physical violence during pregnancy from 5.3% to 9.4%. "In addition to some deaths due to spontaneous miscarriages rapidly complicated by sepsis, membrane rupture and subsequent abortion are often observed in pregnant women suffering episodes of excessive physical violence, falls or accidents. If these women do not receive prompt medical attention, they may die from clinical complications. It is important to remark that any of these abortion deaths cannot be avoided by promoting changes in abortion legislations simply because they are the result of other causes, especially multiple organ failure provoked by septic shock resistant to antibiotic treatment. In fact, these kinds of deaths occur in practically all parts of the world even with the highest maternal healthcare standards, regardless of the legal status of abortion" said Koch.

The researchers stated that implementation of emergency obstetric units and timely access to specialized medical care for high-risk pregnancies, especially in the most vulnerable regions, are key to further reduce maternal mortality in Mexico. "Hundreds of Mexican women continue to die due to hemorrhage, eclampsia and indirect causes; this suggests very concrete strategies that clearly are unrelated to the legal status of abortion" Koch and Calhoun concluded.


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