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A successful medical abortion project in Ethiopia

Prata and colleagues provide us with a success story of a medical abortion project in Ethiopia. The Comprehensive Abortion Care project trained all levels of health providers to provide medical abortion using misoprostol, resulting in a great reduction in complications of unsafe abortion.

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HIV testing in abortion clinics

In her Commentary, Sylvia Bates argues that we need to normalise HIV testing and make it part of our general medical care. Data suggest that testing in abortion clinics should be cost effective, and provides an opportunity for health education amongst women who are known to have high rates of other STIs. Bates' argument is further strengthened by the evidence provided by Briggs et al. of missed opportunities in colposcopy and TOP clinics in this Journal issue.

See page 198

HIV in hiding – missed opportunities for testing

In an editorial from May 2009, the Lancet highlighted “The UK's appalling failure to tackle HIV” [Lancet 2009;373(9678):1820]. At this time, National UK Surveillance data suggested that one in four individuals living with HIV were undiagnosed. Within the diagnosed population, over half were detected ‘late’ with significant health, transmission and financial implications. Learning from the antenatal experience, expanded HIV testing in non-traditional settings (e.g. primary care, medical admissions, emergency departments, general outpatients and community settings) has been shown to be acceptable and feasible. In this paper, the authors highlight ‘missed opportunities’ for HIV testing in TOP and colposcopy services, reinforcing the need to roll out testing beyond the traditional sexual health setting.

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HIV status and contraceptive use in the MIRA Trial

In sub-Saharan Africa, the major burden of HIV is borne in women, many of whom have poor access to health care provision. The Methods for Improving Reproductive healthcare in Africa (MIRA) study was designed to investigate the impact of latex diaphragms and lubricant use on the acquisition of HIV and sexually transmitted infections. In this sub-study, Blanchard et al. examine the effect of learning one's HIV status on contraceptive use, finding little change in contraceptive practice following diagnosis. They highlight the need for greater information, access and provision of longer-acting contraceptive methods, suggesting that this should be embedded within HIV/STI prevention studies and family planning programmes.

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Repeat abortion among women in Britain

Stone and Ingham re-examine data from the National Survey of Sexual Attitudes and Lifestyles (NATSAL2) collected from over 12 000 men and women aged between 16 and 44 years living in Britain in 2000–2001. In 2009, the Office of National Statistics revealed 189 100 abortions, of which 66% were first-time abortion procedures and 34% second- or higher-order abortions. This study examines the characteristics of women undergoing more than one abortion.

See page 209

When does a fetus become a person?

When does the fetus acquire a social recognition of its moral standing and is thus perceived as being a person holding rights who deserves to be protected? Rimon-Zarfaty and colleagues have carried out a survey in Israel and find that Israeli views differ from other English-speaking countries in attributing personhood status to the fetus only at a relatively late stage.

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Does HRT cause breast cancer? Part 3. The WHI: unopposed estrogen

The series of papers by Shapiro et al., reviewing recent studies of breast cancer and hormone replacement therapy (HRT), continues with this critique of the unopposed estrogen arm of the Women's Health Initiative (WHI) trial. The authors conclude that these clinical trial findings, although limited in some respects because of sparse data, are the best evidence produced to date, and they suggest that estrogen therapy without an added progestogen does not increase the risk of breast cancer.

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Diagnosis and management of ectopic pregnancy

Ectopic pregnancy remains a leading cause of first-trimester morbidity and mortality and should be suspected in any woman of reproductive age who presents with abdominal or pelvic symptoms. This up-to-date and comprehensive review focuses on the current diagnostic approach combining clinical examination, ultrasound scanning and measurement of beta human chorionic gonadotrophin. There are still difficulties in making a diagnosis, and a missed diagnosis can be disastrous. The authors highlight the importance of a systematic approach, a clear management plan and follow-up, particularly if a diagnosis of a ‘pregnancy of unknown location’ is made. Management options discussed include surgical, outpatient medical and expectant approaches. For the future, improved screening and diagnostic methods are required: new biomarkers may point the way to the possibility of an earlier definitive diagnosis.

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Referring patients for psychosexual bodywork

In this issue, the Journal's Consumer Correspondent talks to four psychosexual bodywork practitioners and explores whether therapy for sexual problems should include hands-on work. What are the benefits, what are the challenges, and should mainstream health professionals be including bodywork in their referral options?

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Plus ça change…

Continuing his regular series of articles comparing issues that occupied this Journal 25 years ago with those that concern us now, Lindsay Edouard (International Advisory Editor) brings his long experience in working in international health to bear on the increasing problem of population growth. While 25 years ago there was some hope that wider acceptance of modern contraceptive methods would lead to population stabilisation, there were clearly obstacles to be overcome, not least from the forces of conservatism. In this century there have already been several international initiatives addressing the issues of population, women's rights and the spread of HIV but the results of these will take a long time to filter through. A timely and thought-provoking article.

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