Women's reproductive health needs in Russia: what can we learn from an intervention to improve post-abortion care?

Candidate Genes for Age at Menarche Are Associated With Uterine Leiomyoma

Age at menarche (AAM) is an important marker of the pubertal development and function of the hypothalamic-pituitary-ovarian system. It was reported as a possible factor for a risk of uterine leiomyoma (UL). However, while more than 350 loci for AAM have been determined by genome-wide association studies (GWASs) to date, no studies of these loci for their association with UL have been conducted so far. In this study, we analyzed 52 candidate loci for AAM for possible association with UL in a sample of 569 patients and 981 controls. The results of the study suggested that 23 out of the 52 studied polymorphisms had association with UL. Locus rs7759938 LIN28B was individually associated with the disease according to the dominant model. Twenty loci were associated with UL within 11 most significant models of intergenic interactions. Nine loci involved in 16 most significant models of interactions between single-nucleotide polymorphism (SNP), induced abortions, and chronic endometritis were associated with UL. Among the 23 loci associated with UL, 16 manifested association also with either AAM (7 SNPs) or height and/or body mass index (BMI) (13 SNPs). The above 23 SNPs and 514 SNPs linked to them have non-synonymous, regulatory, and expression quantitative trait locus (eQTL) significance for 35 genes, which play roles in the pathways related to development of the female reproductive organs and hormone-mediated signaling [false discovery rate (FDR) ≤ 0.05]. This is the first study reporting associations of candidate genes for AAM with UL.

Strengthening Social and Behavior Change in Postabortion Care: A Call to Action for Health Professionals

Social and behavior change approaches have shown promise for addressing the demand- and supply-side challenges in postabortion care. As implementers seek to improve the quality of postabortion care, systematically integrating long-standing models and emerging approaches, including behavioral economics, human-centered design, and attribute-based models of behavior change, can promote positive health outcomes.

Towards comprehensive early abortion service delivery in high income countries: insights for improving universal access to abortion in Australia

BACKGROUND

Improving access to safe abortion is an essential strategy in the provision of universal access to reproductive health care. Australians are largely supportive of the provision of abortion and its decriminalization. However, the lack of data and the complex legal and service delivery situation impacts upon access for women seeking an early termination of pregnancy. There are no systematic reviews from a health services perspective to help direct health planners and policy makers to improve access comprehensive medical and early surgical abortion in high income countries. This review therefore aims to identify quality studies of abortion services to provide insight into how access to services can be improved in Australia.

METHODS

We undertook a structured search of six bibliographic databases and hand-searching to ascertain peer reviewed primary research in English between 2005 and 2015. Qualitative and quantitative study designs were deemed suitable for inclusion. A deductive content analysis methodology was employed to analyse selected manuscripts based upon a framework we developed to examine access to early abortion services.

RESULTS

This review identified the dimensions of access to surgical and medical abortion at clinic or hospital-outpatient based abortion services, as well as new service delivery approaches utilising a remote telemedicine approach. A range of factors, mostly from studies in the United Kingdom and United States of America were found to facilitate improved access to abortion, in particular, flexible service delivery approaches that provide women with cost effective options and technology based services. Standards, recommendations and targets were also identified that provided services and providers with guidance regarding the quality of abortion care.

CONCLUSIONS

Key insights for service delivery in Australia include the: establishment of standards, provision of choice of procedure, improved provider education and training and the expansion of telemedicine for medical abortion. However, to implement such directives leadership is required from Australian medical, nursing, midwifery and pharmacy practitioners, academic faculties and their associated professional associations. In addition, political will is needed to nationally decriminalise abortion and ensure dedicated public provision that is based on comprehensive models tailored for all populations.

Factors associated with induced abortion among female entertainment workers: a cross-sectional study in Cambodia

OBJECTIVE

To explore risk factors associated with induced abortion among sexually active female entertainment workers (FEWs) in Cambodia.

DESIGN

Cross-sectional study.

SETTING

Phnom Penh and Siem Reap, Cambodia.

PARTICIPANTS

This study included 556 FEWs aged 18-47 years randomly selected from entertainment establishments in the two cities in 2014 using a two-stage cluster sampling method. Data were collected through face-to-face interviews using a structured questionnaire.

PRIMARY OUTCOME MEASURE

History of induced abortion during the time working as a FEW.

RESULTS

Of the total sample, 45.6% reported currently using a contraceptive method with condom (42.4%) being the most common method, followed by pills (25.6%). One-fourth (25%) of the respondents reported having been pregnant at least once, and 21.4% reported having at least one induced abortion during the time working as a FEW. After controlling for other covariates in a multivariate logistic regression model, FEWs with a history of induced abortion remained significantly more likely to be currently working in a karaoke bar (AOR=1.75, 95% CI 1.10 to 2.78), to have worked longer as a FEW (AOR=1.42, 95% CI 1.06 to 1.43), to have had a greater number of sexual partners in the past 12 months (AOR=1.86, 95% CI 1.02 to 1.54), to be currently using a contraceptive method (AOR=1.52, 95% CI 1.01 to 2.29), to be able to find condoms when they needed them (AOR=2.03, 95% CI 1.09 to 3.82), and to report inconsistent condom use with non-commercial partners in the past 3 months (AOR=1.62, 95% CI 1.06 to 3.44).

CONCLUSIONS

This study highlights the high rates of unwanted pregnancies that ended in induced abortions among FEWs in Cambodia. Access of FEWs to quality sexual and reproductive healthcare services is deemed a high priority. Integrated interventions to improve sexual and reproductive health among these vulnerable women should be tailored to reach the most-at-risk groups.

Preconception care: promoting reproductive planning

INTRODUCTION

Preconception care recognizes that many adolescent girls and young women will be thrust into motherhood without the knowledge, skills or support they need. Sixty million adolescents give birth each year worldwide, even though pregnancy in adolescence has mortality rates at least twice as high as pregnancy in women aged 20-29 years. Reproductive planning and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and women. Smaller families also mean better nutrition and development opportunities, yet 222 million couples continue to lack access to modern contraception.

METHOD

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Comprehensive interventions can prevent first pregnancy in adolescence by 15% and repeat adolescent pregnancy by 37%. Such interventions should address underlying social and community factors, include sexual and reproductive health services, contraceptive provision; personal development programs and emphasizes completion of education. Appropriate birth spacing (18-24 months from birth to next pregnancy compared to short intervals <6 months) can significantly lower maternal mortality, preterm births, stillbirths, low birth weight and early neonatal deaths.

CONCLUSION

Improving adolescent health and preventing adolescent pregnancy; and promotion of birth spacing through increasing correct and consistent use of effective contraception are fundamental to preconception care. Promoting reproductive planning on a wider scale is closely interlinked with the reliable provision of effective contraception, however, innovative strategies will need to be devised, or existing strategies such as community-based health workers and peer educators may be expanded, to encourage girls and women to plan their families.

Women's risk of repeat abortions is strongly associated with alcohol consumption: a longitudinal analysis of a Russian national panel study, 1994-2009

Abortion rates in Russia, particularly repeat abortions, are among the highest in the world, and abortion complications make a substantial contribution to the country's high maternal mortality rate. Russia also has a very high rate of hazardous alcohol use. However, the association between alcohol use and abortion in Russia remains unexplored. We investigated the longitudinal predictors of first and repeat abortion, focussing on women's alcohol use as a risk factor. Follow-up data from 2,623 women of reproductive age (16–44 years) was extracted from 14 waves of the Russian Longitudinal Monitoring Survey (RLMS), a nationally representative panel study covering the period 1994–2009. We used discrete time hazard models to estimate the probability of having a first and repeat abortion by social, demographic and health characteristics at the preceding study wave. Having a first abortion was associated with demographic factors such as age and parity, whereas repeat abortions were associated with low education and alcohol use. After adjustment for demographic and socioeconomic factors, the risk of having a repeat abortion increased significantly as women's drinking frequency increased (P<0.001), and binge drinking women were significantly more likely to have a repeat abortion than non-drinkers (OR 2.28, 95% CI 1.62–3.20). This association was not accounted for by contraceptive use or a higher risk of pregnancy. Therefore the determinants of first and repeat abortion in Russia between 1994–2009 were different. Women who had repeat abortions were distinguished by their heavier and more frequent alcohol use. The mechanism for the association is not well understood but could be explained by unmeasured personality factors, such as risk taking, or social non-conformity increasing the risk of unplanned pregnancy. Heavy or frequent drinkers constitute a particularly high risk group for repeat abortion, who could be targeted in prevention efforts.

Correlates of unprotected sexual intercourse among women who inject drugs or who have sexual partners who inject drugs in St Petersburg, Russia

OBJECTIVES

To assess risk for unintended pregnancy, this study describes the correlates of unprotected sexual intercourse (UPSI) among women who inject illicit drugs or who have sexual partners who inject drugs in St Petersburg, Russia.

METHODS

Data from a cross-sectional survey and biological test results collected between 2005 and 2008 from 202 Russian women (143 drug injectors and 59 non-drug injectors) were analysed. Multivariate regression was used to investigate the correlates of UPSI occurring at the women's last sexual act. Independent variables included socio-demographics, age at sexual debut, first sexual encounter perceived as involuntary, number of pregnancies and number of children for which the participant is the primary caretaker, heavy sporadic drinking (i.e. consuming more than five drinks in 2&emsp14;hours at least twice a month), at-risk drinking per the Alcohol Use Disorder Identification Test (AUDIT-C) score, and sexually transmitted infections (HIV-1, syphilis serology, Chlamydia trachomatis and Neisseria gonorrheae).

RESULTS

Sixty-seven percent of women reported UPSI at last intercourse. UPSI was independently associated with heavy sporadic drinking [odds ratio (OR) 2.8, 95% CI 1.2-6.6] and having been pregnant (OR 2.25, 95% CI 1.1-4.6).

CONCLUSIONS

Despite the high risk for HIV acquisition or transmission and unintended pregnancy, condom use among the study population is low. Programmes to investigate and improve contraceptive use, including condom use, among this vulnerable group of women are needed. Such programmes may require identifying and targeting female reproductive health concerns and problem drinking, particularly heavy sporadic drinking, rather than conventional measures of alcohol misuse.

Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia

OBJECTIVE

To describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia.

METHODS

A clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005.

RESULTS

In total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07-9.02) and multiple abortions (OR 4.71; 95% CI, 1.19-18.62).

CONCLUSION

The results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.

Correlates of abortions and condom use among high risk women attending an STD clinic in St. Petersburg, Russia

Background

Many women in Russia rely on abortion as a primary birth control method. Although refusal to use contraceptives, including condoms, may undermine public health efforts to decrease HIV sexual risk behaviors, few studies have investigated the risk factors associated with abortion among women at high risk for HIV. This study sought to identify the correlates of abortions and of lack of condom use among high risk STD clinic patients in St Petersburg Russia.

Methods

Cross-sectional analysis of data collected between 2009 and 2010 from women who had casual or multiple sexual partners in the previous three months was analyzed. Multivariate logistic regression assessed the independent correlates of abortion(s) and no condom use in the prior three months. Independent variables included socio-demographics, at risk drinking per alcohol use disorder identification test (AUDIT-C) criteria, having sex after drinking alcohol, having a sexual partner who injects illicit drugs, and parity.

Results

Of 87 participants, 45% had an abortion in their lifetime and 26% did not use condoms in the prior three months. Abortion was independently associated with low income (OR, 3.33, 95%CI, 1.13-9.78) and at risk drinking (OR, 3.52, 95%CI, 1.24-10.05). Lack of condom use was independently associated with being more likely to have sex after drinking (OR, 3.37, 95%CI, 1.10-10.28) and parity (OR, 3.69, 95%CI, 1.25-10.89).

Conclusions

Programs to increase contraceptive use including condom use among women at high risk for STD/HIV in Russia are needed. Programs to reduce sexual HIV risk and abortion rates must address alcohol misuse and target women with limited income.

Contraception use and unplanned pregnancies among injection drug-using women in St Petersburg, Russia

BACKGROUND

This cross-sectional study estimated the prevalence of contraceptive methods and investigated whether abortion rates influence contraceptive behaviour among injection drug-using (IDU) women in St Petersburg, Russia.

METHODOLOGY

A self-administered questionnaire of behaviour in the last 3 months was applied to a convenient sample of IDU women.

RESULTS

Of 80 sexually active participants, 67% had had an abortion. No participant reported using hormonal contraceptives or intrauterine devices (IUDs). The only valid method of contraception used was condoms, which was reported by half of the participants. Consistent condom use was reported by 22% of participants and was no more likely among those who had an abortion. Condom use was significantly associated with having multiple or casual sex partners [prevalence ratio (PR) 1.75, 95% (confidence interval) CI 1.11-2.78, p = 0.01], having an IDU sex partner (PR 0.55, 95% CI 0.36-0.85, p = 0.029) and with a negative attitude toward condoms (PR 0.53, 95% CI 0.33-0.84, p = 0.01). Abortions were less likely among those who had multiple or casual sex partners (PR 0.69, 95% CI 0.49-0.97, p = 0.03).

CONCLUSIONS

Despite the high prevalence of abortions among IDU women, none reported the use of hormonal contraception or IUDs. Having had an abortion was not associated with greater likelihood of using condoms. Participants mostly used condoms with casual or multiple sex partners, suggesting that condoms were used mainly to prevent HIV/sexually transmitted infection transmission and not to prevent pregnancy. Programmes to prevent unwanted pregnancies and reduce abortion-related health risks among this understudied vulnerable group are needed.

Risk factors for induced abortions in St Petersburg, Estonia and Finland. Results from surveys among women of reproductive age

OBJECTIVES

To compare the risk factors of self-reported abortion in St Petersburg, Estonia and Finland, which are neighbouring areas having different abortion rates.

METHODS

Data from four population-based questionnaire surveys (Finland 1992 and 1999; St Petersburg 2003; Estonia 2004) were used. With the exception of the 1992 Finnish survey (based on interviews) all were postal surveys. There were 1070 respondents in Finland (78% and 52% response rates), 1147 (68%) in St Petersburg, and 5190 (54%) in Estonia.

RESULTS

The prevalence of self-reported abortions was highest among women in St Petersburg and among the two oldest age groups of Russian-speaking Estonians. In all areas women with a history of abortion were more likely to have low education, children, a history of multiple partners and to have had their first intercourse when younger than 18 years. Insufficient use of reliable contraception, both at first and last intercourse, was the only risk factor that was more common in St Petersburg and in Estonia than in Finland. In Estonia, more Estonian than Russian-speaking women used reliable contraceptives.

CONCLUSION

The comparison of three areas suggests that high abortion rates are related to low contraceptive use and not to other risky sexual behaviour.

Trends in family planning in Russia, 1994-2003

CONTEXT

Although Russian women have adequate knowledge of modern contraceptives, their level of use of these methods has been low, and abortion rates remain relatively high.

METHODS

In 1994-2003, sexually active women aged 18-49 were interviewed about their contraceptive use as part of the Russia Longitudinal Monitoring Survey. Trends in contraceptive use were examined. Multivariate analyses were conducted to identify characteristics associated with reliable contraceptive use (IUD use or consistent oral contraceptive use) in 1994 and 2003.

RESULTS

In each year, about 25% of sexually active women had used no contraceptive method in the past month, and 20% had used traditional methods. Prevalence of barrier method use increased from 9% to 21% between 1994 and 2003, while that of IUD use declined from 34% to 21%. These changes were especially pronounced in Moscow and St. Petersburg, and among younger women. Common reasons for nonuse were irregular sexual relations (cited by 29% of nonusers in 2003), desire for pregnancy (22%), perceived inability to get pregnant (15%), feeling that contraceptives are uncomfortable or unpleasant (15%), health problems (11%) and the availability of abortion (6%). In 1994 and 2003, the odds of reliable contraceptive use were elevated among women with at least a secondary education (odds ratios, 1.5-1.7), and were reduced among smokers (0.6-0.7).

CONCLUSIONS

Modern, effective contraceptive use has not increased among sexually active Russian women. Growing use of barrier contraceptives may reflect HIV awareness. Obstacles to effective contraceptive use, such as attitudes and health service factors, need further clarification.