Women in Canada will have access to emergency contraception without a physician's prescription, according to a recent announcement by Health Canada (Press release, Apr 20, 2005). The Society of Obstetricians and Gynaecologists of Canada (SOGC) strongly supports the decision. “It is estimated that 50% of all pregnancies are unintended. Emergency contraception has the potential to significantly reduce the incidence of unintended pregnancy and the number of abortions performed. Given the significant psychological, social and economic impact of improving access to emergency contraception for women across Canada, this is a significant step forward in women's rights and health,” explained Dr. André Lalonde, Executive Vice President of the SOGC. The nature of emergency contraception is that it needs to be taken as soon as possible after unprotected sex and started within a maximum of 72 hours. The SOGC pioneered the struggle to give women access to emergency contraception without a doctor's prescription, beginning its efforts in November 1988.
Cesarean births have increased to 23 percent in the United Kingdom, government figures for 2003–2004 revealed in March 2005, suggesting that last year's halt in the rise was “just a blip in a long-term trend of increasing medical intervention in childbirth”(Guardian Apr 1, 2005). The cesarean section rate has climbed from under 3 percent in the 1950s to 12 percent in 1990–1991, and appeared to plateau at 22 percent last year, which was no change from the year before. One-half of the cesareans (11%) are elective, and the remainder emergency cesareans. Commenting on the rise, the Royal College of Midwives said the cesarean rate was too high. “We are disappointed and troubled by the rise of the caesarean rate, despite our support for normal births,” said Dame Karlene Davis, its general secretary. “We believe that caesarean delivery is appropriate and beneficial in only 10 to 15% of all births, as specified by the World Health Organisation. As it stands, one in four babies being delivered by caesarean is simply too many.” The College was concerned that some cesareans were being carried out “as a matter of course rather than medical necessity,” Dame Karlene said. The figures include only those National Health Service maternity units that have collected data, that is, approximately 72 percent. They do not include private hospitals, where there is a much higher cesarean section rate. “We find it disappointing that some hospitals have not submitted any usable records. We believe that trusts have a duty to produce details of the maternity care they provide in order to be accountable to both those that fund the service and those that use the service,” said Miranda Dodwell of the information service.
Two attempts by the United States to insert antiabortion statements into resolutions at the recent United Nations conference on the status of women were defeated (BMJ 2005;330:621). In an opening speech reviewing progress in the decade since the 1995 Beijing conference, UN secretary general Kofi Annan noted that there was progress in women's improved life expectancy, ability to earn, and lower fertility rates, and girls’ access to primary education. He said that the situation was worse in other areas. Trafficking in women and children was increasing, and HIV/AIDS was rising among young women.
At the beginning of the 2-week meeting, Ellen Sauerbrey, the US ambassador to the meeting, said that the United States would not reaffirm the Beijing platform, which the United States had helped to draw up, unless a statement was inserted saying that the Beijing platform did not create new international human rights, including the right to abortion. The Beijing platform deals with abortion as a public health issue. It says that abortion should be safe where it is legal, and that no criminal action should be taken against women who have an illegal abortion. After complaints by many delegates, Ms Sauerbrey backed down, saying that she understood that the proposed amendment was redundant. Since 2002, the United States has withheld funds for the UN population fund, on the grounds that some money might support coercive birth control in China. The United States has never ratified the UN's 1979 Convention on the Elimination of All Forms of Discrimination against Women.
Routine episiotomy is unnecessary and may raise the risk of certain complications, according to a recent systematic review of trials looking at the outcomes of routine episiotomy (JAMA 2005;293: 2141–2148). It is estimated that up to 35 percent of vaginal deliveries involve routine episiotomy in the United States. Principal author Dr. Katherine Hartmann, from the University of North Carolina at Chapel Hill, and her colleagues concluded, “Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.” Of 986 articles screened in a search of articles published between 1950 and 2004, the researchers identified 26 that met their inclusion criteria. Benefits previously ascribed to routine episiotomy include better wound healing in the short term and decreased urinary and fecal incontinence in the long term. Dr. Hartmann does not believe more studies are needed. “The literature is fairly convincing and there is very little precedent for using a procedure that doesn’t show benefit and has a risk of harm.” She told Reuters Health (May 4, 2005), “I hope after our findings come out there will be a decline in use.” For additional information on the subject, see the article by Ian Graham et al, “Episiotomy Rates Around the World: An Update,” in this issue of Birth.
Re-approval of the over-the-counter contraceptive, the Today® sponge, has been granted by the U.S. Food and Drug Administration (FDA) more than a decade after it was taken off the market because of manufacturing issues unrelated to safety (ObGyn News 2005;40(10):10). The Today® sponge, manufactured by Allendale Pharmaceuticals, Inc., in New Jersey, is the same device that was taken off the market in 1994, and was the first successful product to incorporate a spermicide into a barrier contraceptive. It provides a polyurethane foam barrier between the cervix and sperm, and continually releases 125–150 mg of nonoxynol-9 into the vagina and can be used for 24 hours. It must be left in place for at least 6 hours after the last act of intercourse and does not protect against sexually transmitted diseases, the company said. In multicenter clinical trials of more than 1,800 women, conducted in the U.S. and 8 other countries before being pulled from the market, the sponge was 89 percent effective in preventing pregnancies during 1 year among 939 multiparas and 91 percent among 915 nulliparas, when used properly. The Today® sponge is expected to be available for distribution over the counter in summer 2005.
Training traditional birth attendants (TBAs) and using them in an improved health system in a rural district in Pakistan were effective measures in reducing perinatal and maternal mortality, according to a recent study (N Engl J Med 2005;352:2091–2099). The investigation, conducted by Jokhio et al, was a cluster-randomized, controlled trial involving 7 subdistricts (talukas). Three talukas were randomly assigned to an intervention group of 9,184 women (90.8%) and 4 talukas to a control group who received usual care. The intervention group was given antenatal care by trained TBAs, who were supplied with disposable safe-delivery kits and linked with established services and documented processes and outcomes. The authors concluded, “This model could result in large improvements in perinatal and maternal health in developing countries.” In commenting on the study, Dr. Jelka Zupan of the World Health Organization noted, “The highest neonatal mortality rates and rates of stillbirth occur in sub-Sahara Africa, followed by Asia and Latin America.…A skilled provider can support a woman during childbirth in a manner that is in keeping with her culture and beliefs and can promote breast-feeding, detect complications, and organize care by obstetricians or pediatricians as needed.…Yet half the women in the world still give birth at home without skilled care.”
Contraceptive use is almost universal among women of reproductive age in the United States: 98 percent of women who had ever had intercourse had used at least one contraceptive method, according to a recent report, Use of Contraception and Use of Family Planning Services in the U.S.: 1982–2002, from the National Center for Health Statistics (Advance Data 2004;350, Dec 10). The leading method of contraception was the oral contraceptive pill, used by 11.6 million women; the second was female sterilization, used by 10.3 million women; and the third was the condom, used by approximately 9 million women and their partners. The condom is the leading method at first intercourse; the pill is the leading method among women under age 30 years; and female sterilization is the leading method among women age 35 years and older. During the 20 years between 1982 and 2002, the percentage of women who had ever had a partner using the male condom rose from 52 percent in 1982 to 90 percent in 2002; the percentage of women who had ever had a partner who used withdrawal increased from 25 percent in 1982 to 56 percent in 2002. Premarital use of contraception is also a key measure—before 1980 only 43 percent of women (or their partners) used birth control at first premarital intercourse, but by 1999–2002 the proportion using a method at first premarital intercourses had risen to 79 percent.