Where C-sections are most common in the U.S. and why they're performed

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Evaluating Quality of Care for Sexually Transmitted Infections in Different Clinical Settings

We examined quality of care across different clinical settings within a large safety-net hospital in Massachusetts for patients presenting with penile discharge/dysuria or vaginal discharge.

Using a modified Delphi approach, a list of sex-specific sexually transmitted infection (STI) quality measures, covering 7 domains of clinical care (history, examination, laboratory testing, assessment, treatment, additional screening, counseling), was selected as standard of care by a panel of 5 STI experts representing emergency department (ED), obstetrics/gynecology (Ob/Gyn), family medicine (FM), primary care (PC), and infectious disease. Final measures were piloted with 50 charts per sex from the STI Clinic and age, sex, and visit date-matched charts from PC, FM, ED, and Ob/Gyn. Performance was scored as compliance among individual measures within 7 domains, standardized to add up to one to adjust for variable number of measures per domain, with an overall score of 7 indicating complete adherence to standards.

Expert review process took 2 weeks and resulted in 24 and 34 final measures for male and female patients, respectively. Performance on 7 clinical domains ranged from 3.16 to 4.36 for male patients and 3.17 to 4.33 for female patients. Sexually transmitted infection clinic seemed to score higher on laboratory testing, additional screening, and counseling, but lower on examination and assessment, and ED seemed to score higher on examination and treatment, PC and FM on laboratory testing for male patients and on examination and treatment for female patients, and Ob/Gyn on treatment.

An instrument to discern standard of care and identify strengths and weaknesses in specific domains of clinical documentation for patients presenting with STI complaints can be developed and implemented for quality evaluation across care settings. Further research is needed on whether these findings can be integrated into site-specific quality improvement processes and linked to cost analyses.

Purchase full article at:  http://goo.gl/KbGT84

By:  Sequeira S1, Morgan JR, Fagan M, Hsu KK, Drainoni ML.

• 1From the *Boston University School of Medicine, Boston, MA; †Massachusetts Department of Public Health, Boston, MA; and ‡Boston University School of Public Health, Boston, MA. 

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Zero Tolerance Against Patriarchal Norms? A Cross-Sectional Study of Swedish Physicians' Attitudes Towards Young Females Requesting Virginity Certificates or Hymen Restoration

Many countries, Sweden among them, lack professional guidelines and established procedures for responding to young females requesting virginity certificates or hymen restoration due to honour-related threats. 

The purpose of the present survey study was to further examine the attitudes of the Swedish healthcare professionals concerned towards young females requesting virginity certificates or hymen restorations. The study indicates that a small majority of Swedish general practitioners and gynaecologists would accommodate these patients, at least given certain circumstances. But a large minority of physicians would under no circumstances help the young females, regardless of speciality, years of practice within medicine, gender, or experience of the phenomenon. Their responses are similar to other areas where it has been claimed that society should adopt a zero tolerance policy against certain phenomena, for instance drug policy, where it has also been argued that society should never act in ways that express support for the practice in question. However, this argument is questionable. 

A more pragmatic approach would also allow for follow-ups and evaluation of virginity certificates and hymen restorations, as is demonstrated by the Dutch policy. Hence, there are some obvious advantages to this pragmatic approach compared to the restrictive one espoused by a large minority of Swedish physicians and Swedish policy-makers in this area.

Full article at:  http://goo.gl/F8uupm

By:  Juth N1, Lynöe N1.

• 1Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden. 

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Progression or Regression? – Strengths and Weaknesses of the New Munich Nomenclature III for Cervix Cytology

Since 01. 01. 2015 the new Munich nomenclature III for gynaecological diagnostics of the cervix has been in force. The changes have led to controversial scientific discussions. This study reports for the first time on the consequences.

The present data are based on smear screening results for the year 2014. The data of 63 134 patients were evaluated. 

2.27 % of all smears were remarkable. Group IIa was assigned to 0.91 %. Group II-p was somewhat more frequently recorded than group IIID1 (0.59 vs. 0.53 %). Groups IIID1 and IIID2 were found in 0.53 and 0.61 %, respectively, of the cases. Agreement with histology was found in 36.84 and 44.68 %, respectively. Glandular lesions represented the most frequent changes in group III. Histological clarification was obtained for 0.18 % of all remarkable findings. The relative incidence of high-grade precancerous conditions (CIN III) and invasive tumours amounted to 0.1 %. 

A close communication between gynaecologists and cytologists is mandatory for the correct usage of the new nomenclature. The future annual statistics of the health insurances can now be analysed in more detail. A statistical classification of glandular epithelial changes is now also possible for the first time. The heterogeneous group IIa constitutes an unnecessary uncertainty for patients and physicians. The splitting of the group IIID does not appear to have any advantage for the further clinical management. Further studies are needed to show whether or not the classification can stand up to international comparisons.

Below:  Histological clarification of 12 cases with unclear or equivocal findings according to the Munich nomenclature III (groups III-g [n = 11] and III-p [n = 1]). The cytological finding III-p correlates with the histological diagnosis of an invasive vaginal cancer.

Full article at:  http://goo.gl/oveUJM

By:  Z. Hilal, C. Tempfer, S. Schiermeier, J. Reinecke, C. Ruppenkamp, and Z. Hilal

¹ZYDOLAB – Institut für klinische Zytologie und Immunzytochemie, Dortmund

²Abteilung für Gynäkologie und Geburtshilfe, Ruhr Universität Bochum, Herne

³Abteilung für Gynäkologie und Geburtshilfe, Universität Witten/Herdecke, Witten

⁴Institut für Pathologie, Universitätsklinikum Düsseldorf, Düsseldorf

Correspondence Dr. med. Ziad Hilal ZYDOLAB – Institut für klinische Zytologie und Immunzytochemie, Markt 10, 44137 Dortmund, ; Email:ed.balodyz@lalih.z

 

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Expanding Availability of Safe Abortion Services through Private Sector Accreditation: A Case Study of the Yukti Yojana Program in Bihar, India

Recognizing the need to increase access to safe abortion services to reduce maternal mortality and morbidity, the state government of Bihar, India introduced an innovative mechanism of accrediting private health care facilities. The program, Yukti Yojana (‘a scheme for solution’), accredits eligible health facilities and supports them in providing abortion-related services free of charge to rural and low-income urban women. This paper describes implementation of Yukti Yojana.

A descriptive analysis of abortion services provided under the Yukti Yojana program was conducted using four data sources: 1) assessment of accredited facilities over 6 months; 2) induced and incomplete abortion service registers; 3) client exit interviews and associated direct observation of client-provider interaction for a sample of accredited facilities; and 4) in-depth interviews with providers and key stakeholders responsible for providing or influencing abortion services. These analyses assessed characteristics of women receiving abortion services, quality of care and client satisfaction, and barriers and facilitating factors of a successful accreditation process.

Forty-nine private facilities were accredited during the first two years of the program, and 84 % had begun providing abortion services, in all 27,724 women were served. Overall, 53 % of beneficiaries reported holding a “Below Poverty Line” card, while 71 % had low living standard. The majority of women (n = 569) reported satisfaction (90 %) with their care, while 68 % perceived good quality of services. Having a government-led initiative was considered a key element of success, while stringent requirements for site approval, long waiting time for accreditation, complicated and delayed reimbursement process and low reimbursement fees for abortion services were identified as barriers to implementation.

Yukti Yojana provides a model for successfully involving private OB/GYNs and general physicians to deliver safe abortion services to poor women on a large scale and offers additional evidence that public-private partnerships can be used to ensure availability of high-quality maternal health services to women in low-income countries. Private facility accreditation also offers a promising solution to the limited availability of safe abortion services in low resource settings such as Bihar, India.

Below:  Location of 49 private sites accredited under YuktiYojana program as of May 2013 (stars indicate accredited health facilities)

Below:  Three-monthly moving average of abortion caseload per month per site at Yukti Yojana accredited facilities between May 2012 and July 2014

Full article at:  http://goo.gl/177iul

By:  Sushanta Kumar Banerjee^1*, Kathryn Louise Andersen², Deepa Navin¹ and Garima Mathias¹

¹Ipas Development Foundation, E-63 Vasant Marg, Vasant Vihar, New Delhi 110 057, India

²Ipas, 300 Market St., Suite 200, Chapel Hill 27516, NC, USA

 

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