Contraceptive and Reproductive Health Technologies
Research and Utilization Program

April to June 2007

Research

*         Hormonal Contraceptives Have Little Effect on Carbohydrate
Metabolism in Healthy Women

*         Future Appears Bright for Contraceptive Implants in Kenya

*         Progestin-Only Injectables Appear Safe for Women with Sickle
Cell Disease

*         New Review Confirms Benefits of "No-Scalpel" Vasectomy

*         Unintentional Discontinuation of Injectable Contraceptives Can
Be Prevented

*         Multiple Strategies Needed to Increase the Use of the
Intrauterine Device

Research to Practice

*         Female Condom Research to Become More Standardized

*         USAID Supports Training on Best Practices in Madagascar

*         Support for Community-Based Distribution Grows Through Online
Forum

*         Workshop Improves Capacity to Expand Pilot Interventions in
Africa

*         USAID-Supported Job Aids Prove Useful in the Dominican
Republic

*         Toolkit for the Intrauterine Device Now Available on CD-ROM

*         Interagency Youth Working Group Launches Comprehensive Online
Resource

 

Research

Hormonal Contraceptives Have Little Effect on Carbohydrate Metabolism in
Healthy Women

A new Cochrane review from Family Health International suggests that the
use of hormonal methods of family planning have little effect on how
healthy women metabolize sugars and starches. However, little is known
about the effects of these contraceptives on the use of carbohydrates in
women at risk for diabetes. 

This is the first review of randomized controlled trials to consider the
impact of hormonal contraceptives on carbohydrate metabolism in women
without diabetes. The authors reviewed 24 randomized controlled trials,
most of which compared oral contraceptives that varied by type and dose
of progestin and estrogen. (Some trials examined other hormonal methods,
such as injectables, the vaginal ring, and implants.) Although some
progestins caused less disturbance than others on carbohydrate
metabolism, none of the effects were considered clinically important. 

Unfortunately, no trials were available to determine whether hormonal
contraceptives had a greater effect on metabolism in overweight women,
who are at higher risk of diabetes. Because diabetes is a disease in
which the body does not properly use carbohydrates, any significant
changes in metabolism could be a reason for concern.

To read more about this systematic review, published in the Cochrane
Database of Systematic Reviews, see:

http://dx.doi.org/10.1002/14651858.CD006133.pub2

 

Source

Lopez LM, GrimesDA, Schulz KF. Steroidal contraceptives: effect on
carbohydrate metabolism in women without diabetes mellitus. Cochrane
Database Syst Rev 2007;(2):CD006133.

Future Appears Bright for Contraceptive Implants in Kenya

Contraceptive implants appear to have a bright future in Kenya,
according to a recent USAID-supported study from Family Health
International. The demand has remained high and the costs have dropped
substantially since implants were first introduced to Kenya more than 20
years ago.

The authors of the study note that 45 percent of all pregnancies in the
country are unintended-suggesting there is a great unmet need for
implants. They estimate that roughly 26,000 unintended pregnancies could
be averted over the next five years if 100,000 women switched from oral
contraceptives to implants.

Kenya has the facilities to provide contraceptive implants and appears
poised to expand these services. Unfortunately, these facilities are
often short of stock because donors have historically invested more
heavily in short-term methods, like oral contraceptives. The authors
argue that donors should reconsider the role of implants because studies
have shown that they are more cost-effective than oral contraceptives. 

Read more about this research, published in Contraception, at:

http://dx.doi.org/10.1016/j.contraception.2007.02.008

 

Source

Hubacher D, Kimani J, Steiner MJ, Solomon M, Ndugga MB. Contraceptive
implants in Kenya: current status and future prospects. Contraception
2007;75:468-473.

Progestin-Only Injectables Appear Safe for Women with Sickle Cell
Disease

A Cochrane review from Family Health International, conducted with
partial support from USAID, suggests that women with sickle cell disease
may safely use the progestin-only injectable depot medroxyprogesterone
acetate (DMPA). These findings are particularly relevant in sub-Saharan
Africa, where the popularity of DMPA is increasing and sickle cell
disease is widespread. 

Sickle cell disease is an inherited blood disorder in which red blood
cells can become sickle-shaped, making it hard for them to pass through
small blood vessels. People of African descent are at a high risk of
having the condition. With only one small, randomized controlled trial
of 25 women with sickle cell disease available, the authors of the
review found that DMPA use appeared to be safe. The women who were using
DMPA were less likely than the women who were not using the
contraceptive to suffer from bone pain associated with the disease. 

These results are in agreement with current recommendations from the
World Health Organization that no restrictions be placed on the use of
DMPA and other progestin-only methods of family planning by women with
sickle cell disease. 

The review was published in the Cochrane Database of Systemic Reviews.
To read more about the use of hormonal methods in women with sickle cell
disease, see:

http://dx.doi.org/10.1002/14651858.CD006261.pub2. To read more about
Cochrane reviews in general, see:

http://www.cochrane.org/reviews/clibintro.htm

 

Source

Manchikanti A, Grimes DA, Lopez LM, Schulz KF. Steroid hormones for
contraception in women with sickle cell disease. Cochrane Database Syst
Rev 2007(2):CD006261.

New Review Confirms Benefits of "No-Scalpel" Vasectomy

Two different approaches can be used to access a man's sperm-carrying
ducts at the start of a vasectomy. It turns out that one of the
approaches has more benefits for both surgeons and their patients,
according to a recent Cochrane review from Family Health International
and colleagues from the United States, New Zealand, the Netherlands, and
Nepal.  

The ducts, known as the vasa deferentia, can be accessed using either a
"traditional" approach or a "no-scalpel" approach. In the traditional
approach, a scalpel is used to cut the skin of the scrotum in one or two
places. In the no-scalpel approach, the scrotal skin is punctured with a
sharply pointed, forceps-like instrument. 

The new review evaluates two randomized controlled trials comparing the
two approaches. The review confirms earlier findings that the no-scalpel
approach takes less time to perform, that it is associated with a
quicker return to sexual activity, and that it causes less bleeding,
infection, and pain. Both approaches appear to be equally effective in
their contraceptives effects, but the no-scalpel approach may be a more
practical choice for surgeons trained in this particular method.

To read more about this review, conducted with partial support from
USAID and published in the Cochrane Database of Systematic Reviews, see:

http://dx.doi.org/10.1002/14651858.CD004112.pub3

 

Sources

Cook LA, Pun A, van Vliet H, et al. Scalpel versus no-scalpel incision
for vasectomy. Cochrane Database Syst Rev 2007;(2):CD004112.

Unintentional Discontinuation of Injectable Contraceptives Can Be
Prevented

USAID-supported research from Family Health International, the
University of Cape Town, and the Walter Sisulu University in South
Africa shows that being late for a re-injection can lead to
unintentional discontinuation of injectable contraceptives. Results of
the study also suggest that family planning providers can take certain
steps to help clients who do not wish to stop using the method.

The study included more than 1,000 users of injectable contraceptives
who were receiving a re-injection at one of 10 family planning clinics
in two South African provinces. Approximately half of the women were
late for their injections. Nearly a third were late by two weeks or
less. 

Current recommendations from the World Health Organization state that a
woman may receive a re-injection without the need to rule out pregnancy
even if she is up to two weeks late for her appointment. However, a
woman who returns to the clinic after this two-week "grace period" may
be at risk of an unintended pregnancy. In this case, the World Health
Organization recommends that a woman should not receive another
injection until pregnancy is ruled out. 

Nevertheless, a substantial portion of women who returned to the South
African clinics within the grace period were denied a re-injection. Many
were not given an alternative contraceptive method or were told to
return to the clinic only after they had begun menstruating. 

Providers should counsel the users of injectable contraceptives about
the timing of their next injection and the consequences of being more
than two weeks late. They should also be careful not to deny a woman a
re-injection if she returns to the clinic within the recommended grace
period, and they should provide effective contraceptive alternatives to
a woman who cannot have another injection until pregnancy is ruled out.


To read this study, published in International Family Planning
Perspectives, see:

http://www.guttmacher.org/pubs/journals/3306607.pdf
<http://www.guttmacher.org/pubs/journals/3306607.pdf>  (254 KB)

 

Source

Baumgartner JN, Morroni C, Mlobeli RD, et al. Timeliness of
contraceptive reinjections in South Africa and its relation to
unintentional discontinuation. Int Fam Plan Perspect 2007;33(2):66-74.

Multiple Strategies Needed to Increase the Use of the Intrauterine
Device

USAID-supported research from Family Health International and the Kenya
Ministry of Health highlights the importance of targeting the factors
associated with supply and demand when attempting to increase the use of
contraceptives. 

In the study, scientists determined how an intervention to promote the
intrauterine device (IUD) among clinic-based providers and
community-based distribution (CBD) agents would affect uptake of the
IUD. The CBD agents were included, in part, in an attempt to increase
the demand for the IUD within the communities they served.

Forty-five public-health facilities from five districts in Kenya were
included in the study. In each district, one district nurse or deputy
was trained as a "detailer" to educate and motivate the providers and
the CBD agents about the IUD. The scientists found that promoting the
IUD among both providers and CBD agents modestly increased uptake when
compared with no promotion. Promoting the IUD among only providers or
only CBD agents did not have the same effect. 

The intervention was considered too expensive for the small outcome it
achieved and is therefore not recommended for replication. To read more
about the study, published in the Journal of Biosocial Science, see:

http://dx.doi.org/10.1017/S0021932007002027

 

Source

Wesson J, Olawo A, Bukusi V, et al. Reaching providers is not enough to
increase IUD use: a factorial experiment of 'academic detailing' in
Kenya. J Biosoc Sci 2007;April 20:1-14[Epub ahead of print].



Research to Practice

Female Condom Research to Become More Standardized

Family Health International's USAID-supported research on the female
condom has influenced the development of new recommendations from the
World Health Organization on how future research on the female condom
should be designed and analyzed.

Understanding female-condom failure is essential for improving the
device. Standardized terms and definitions related to male-condom
failure were proposed more than a decade ago, and have since been
accepted by regulatory bodies and the research community as a means of
evaluating the function and performance of male condoms. The same is not
true for female condoms. 

In January 2006, the World Health Organization convened a
technical-review committee to develop a standard list of terms and
definitions related to the failure of female condoms. Participants
included representatives of Family Health International, CONRAD, and
other international organizations with extensive experience in
female-condom research. Nonclinical breakage, clinical breakage,
slippage, and total clinical failure are among the eight terms that the
committee identified and clearly defined. 

If scientists adopt the standardized terms and definitions for the
female condom, it will be easier to compare results of different studies
and to more accurately determine failure rates. The full list of terms
and definitions was released in the April 2007 issue of Contraception.
To read more, see:

http://dx.doi.org/10.1016/j.contraception.2006.10.003

USAID Supports Training on Best Practices in Madagascar

In April and May, Family Health International and the Ministry of Health
in Madagascar held three USAID-supported workshops to train 57 health
providers and program managers from three districts on a new package of
"best practices" in reproductive health. 

The package included a "pregnancy checklist" to rule out pregnancy among
non-menstruating clients and "systematic screening" to reduce clients'
unmet health needs. The pregnancy checklist, developed by Family Health
International, uses six simple questions to help providers quickly and
effectively rule out pregnancy so that they can safely offer a
non-menstruating woman her contraceptive of choice. Systematic
screening, developed by the Population Council's FRONTIERS Program, is a
simple strategy to increase the number of health services a client can
receive during a single visit to a clinic. 

These two best practices will be implemented at five clinics in each of
the three districts where the trainings were held (Antananarivo
Atsimondrano, Moramanga, and Ambositra). The participants of the
workshops-all members of the Ministry of Health-were trained how to
implement, manage, and evaluate the best practices in a district and a
clinic. Lessons learned from the workshop will eventually be used to
expand the use of the practices throughout Madagascar. 

For more information on the pregnancy checklist and systematic
screening, see:

http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/pregnancy/index.ht
m and

http://www.popcouncil.org/frontiers/projects_pubs/topics/SLR/SystematicS
creeningManual.html.

Support for Community-Based Distribution Grows Through Online Forum

Through a close partnership supported by USAID, Family Health
International and Management Sciences for Health co-hosted a week-long
online forum to give global health professionals an opportunity to share
experiences and provide guidance on the community-based distribution
(CBD) of injectables.

"Addressing Unmet Need for Family Planning in Rural Areas: Introducing
Community-Based Distribution of Injectable Contraceptives" was broadcast
via the Global Exchange Network for Reproductive Health from May 21 to
May 25, 2007. Nearly 200 participants from 19 countries joined the
online exchange of ideas about this relatively new technique for
improving contraceptive access.

General themes that emerged from the forum included overall support for
the CBD of injectables and the need to dispell some myths and
misinformation about the technique. The participants also discussed the
need to provide adequate training to CBD agents, and the need to create
strong relationships between community-based and clinic-based services. 

The CBD of injectables was successfully introduced to parts of Asia and
Latin America decades ago, but the technique is new to Africa. Pilot
projects have begun in Madagascar and are expanding in Uganda. Kenya is
starting a pilot project now. Several other countries in sub-Saharan
African are also considering the technique.

See http://www.fhi.org/en/RH/Pubs/servdelivery/cbd_dmpa/index.htm to
read more about the CBD of injectables. For more on the Global Exchange
Network for Reproductive Health-a network of the Leadership, Management
and Sustainability Program of Management Sciences for Health-see:

http://www1.msh.org/projects/lms/ProgramsAndTools/SustainabilityAndScali
ngUp/GEN.cfm.

Workshop Improves Capacity to Expand Pilot Interventions in Africa

Family Health International hosted a USAID-supported regional
workshop-held in Nairobi from May 22 to May 24, 2007-on planning and
managing the expansion or "scale up" of successful pilot interventions
for improving reproductive health. 

Many small interventions with the potential for improving reproductive
health programs on a larger scale are never expanded because of a lack
of proper planning. This workshop was conducted to build the capacity of
Family Health International and its local partners, including the Kenya
Ministry of Health, to take powerful research results and ensure that
they are used on a broader scale. The workshop was presented by
Management Systems International, the developer of a field-tested
framework for scaling up pilot interventions in the developing world.
More than 20 representatives participated from the Kenya Ministry of
Health and from Family Health International in Kenya, Uganda, and
Madagascar. 

Using existing case studies, the workshop focused on several issues: how
to decide early on whether an intervention can be effectively scaled up;
how to create a broad strategy for scaling up; and how to best implement
that strategy. Participant feedback has been positive, and Family Health
International is already planning to use the knowledge gained from the
workshop in its current and future projects. 

To read more about the framework that served as the basis for the
workshop, see:

http://www.msiworldwide.com/documents/MacArthur%20Framework_July-06-high
%20quality.pdf (1.04 MB)

USAID-Supported Job Aids Prove Useful in the Dominican Republic

A recent evaluation of four job aids developed by Family Health
International, with support from USAID, demonstrates their usefulness
among providers of family planning in the Dominican Republic. 

The four job aids-checklists to help providers determine whether clients
can safely begin using their contraceptive method of choice-were
disseminated by the Ministry of Health in May 2006 during a nationwide
series of training workshops. Approximately 1,700 doctors and nurses who
provide family planning in the Dominican Republic attended the
workshops. 

Between February and May 2007, the impact of the dissemination was
evaluated in 34 clinics in two provinces. At least one job aid was found
in 65 percent of the clinics, and more than half of the 61 providers who
were interviewed had used the material at least once in their work and
had found the checklists very useful.

Training on how to use the checklists also continues throughout the
developing world. In April, the Kenya Ministry of Health's Division of
Reproductive Health disseminated 5,000 sets of checklists, specifically
adapted for the Kenyan context, and launched an initiative to train
providers throughout the country to use them. They have also posted the
checklists on their Web site, and plan to produce them in Kiswahili for
further dissemination. In May, Family Health International also
pre-tested new checklist-training guides, which were used to train 114
reproductive-health trainers and service providers from both Kenya and
Uganda. 

To view the checklists online, see:

http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/index.htm. To see
the versions adapted for Kenya, see:

http://www.drh.go.ke/html/announcements2.asp?announcementid=18.

Toolkit for the Intrauterine Device Now Available on CD-ROM

A CD-ROM version of the popular IUD Toolkit is now available to those
who wish to increase understanding of the intrauterine device (IUD) or
who wish to initiate or improve IUD programs. 

Developed by the IUD Subcommittee of USAID's Maximizing Access and
Quality Initiative, the toolkit is a free, online resource providing
comprehensive and evidence-based information about IUDs through
documents, presentations, case studies, and educational tools. Between
January and June 2007, the online toolkit received more than 45,000
visitors from around the world. 

Family Health International played a pivotal role in engaging more than
a dozen leading international reproductive health organizations to
develop the IUD Toolkit. The organization has also contributed to more
than 35 years of high-quality research showing that the IUD is one of
the safest and most reliable contraceptives available today. 

To access the toolkit and download full-text resources on the IUD, see:

http://www.iudtoolkit.org <http://www.iudtoolkit.org/> . To order copies
of the CD-ROM version, send an email to [log in to unmask]

Interagency Youth Working Group Launches Comprehensive Online Resource

The new USAID-supported Interagency Youth Working Group (IYWG) recently
launched a Web site for reproductive health professionals working with
youth in developing countries. "Resources on Youth Reproductive Health
and HIV/AIDS" is a unique global site featuring publications, research
tools, training materials, guidance for programs, and an easily
searchable database of more than 900 recent resources related to youth. 

The site is hosted by the INFO Project, Johns Hopkins Bloomberg School
of Public Health Center for Communications Programs, with content
managed by Family Health International. More than 15 organizations
collaborated to create the site. 

The IYWG Group is a network of nongovernmental organizations, donors,
and cooperating agencies supported by USAID to improve reproductive
health and prevent HIV/AIDS among young people ages 10 to 24 years. To
read more about IYWG and its first official meeting, held in May 2007,
see:

http://www.infoforhealth.org/youthwg/iywg/7may07.shtml.

To view the new Web site, see:

http://www.youthwg.org <http://www.youthwg.org/> .



Compiled by Kerry Wright Aradhya, William Finger, and Michael Szpir

 

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